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JAPOSUAV F HULKA 
UNC, OEPT. OF OT-GYM 
CHADEL HILL. M. C. 



MO 
27514 



• «r -m^ 



MEDICAL JOURNAL 



The Official Journal of the NORTH CAROLINA MEDICAL SOCIETY D D D July 1981 , Vol. 42, No. 7 



-A 



Backgrounder Information Sheet 
NC PSROs Temporarily 

Escape Budget Ax Facing 467 

N.C. Medical Society Staff 

Original Articles 
The Protective Properties of 

Dietary Fiber 467 

Denis P. Burkitt, M.D. 

High Risk Indicators of Fetal 
and Neonatal Mortality in 

Durham County, N.C 472 

CraigD. Turnbull, M.P.H., Ph.D., 
John D. Fletcher, M.D., M.P.H., 
and Anne B. Klein, A.B. 

Hereditary Deficiency of 

Thyroxine-Binding Globulin 475 

William D. Wilson, Jr., M.D., and 
Robert P. Schwartz, M.D. 

Basic Science Review 

Hymenoptera Venom Allergy — 
From the Immunology Research 
Laboratory to Clinical Practice . . 477 
Donald R. Hoffman, Ph.D. 

Special Articles 

Message of the President to the 

House of Delegates 481 

M. Frank Sohmer, Jr., M.D. 

Annual Address of the President . . 483 
M. Frank Sohmer, Jr., M.D. 

Attachment of a Physician's 
Assistant to An English General 

Practice 485 

B.L.E.C. Reedy, M.B., 

M.R.C.G.P., 

T. I. Stewart, M.D., F.R.C.G.P., 

and J. B. Quick, PA-C 

Mini-Feature 

Toxic Encounters of the 

Dangerous Kind — Are Your 

Patients Speeding? 489 

Ronald B. Mack, M.D. 



Editorials 

Suggestions for Authors 490 

Why Physician's Assistants? 493 

Practice Management 494 

Correspondence 

Pharmacy and Medicine 496 

William W. Fore, M.D., and 
Stephen W. Shearer, M.S. 

Bulletin Board 

New Members of the State Society 498 

What? When? Where? 499 

News Notes from the Duke 
University Medical Center 500 

News Notes from the Bowman Gray 
School of Medicine of Wake 

Forest University 504 

News Notes from the East Carolina 

University School of Medicine . . 506 
News Notes from the University of 
North Carolina-Chapel Hill 
School of Medicine and North 

Carolina Memorial Hospital 511 

American College of Physicians ... 515 
Federation of State Medical Boards 515 

In Memoriam 516 

Classified Ads 517 

Index to Advertisers 518 



1981 Committee Conclave: Sept. 23-27, 
Southern Pines 

1982 Conference for Medical Leadership: 

February 5-6, Winston-Salem 
1982 Annual Sessions: May 6-9, 
Pinehurst 



Feelii^^ ^1 



Some people feel that I am misused and overused 
and that Fm prescribed too often and for too many kinds 
of problems. 

The FACT is that approximately eight million people, 
or about 5 percent of the U.S. adult population, will use me 
during the current year. By contrast, the national health 
examination survey (1971-1975) found that 25 percent of 
the U.S. adult population experiences moderate to severe 
psychological distress. Additionally, studies of patient atti- 
tudes revealed that most patients have realistic views regard- 
ing the limitations of tranquilizers and a strong conservatism 
about their use, as evidenced by a general tendency to 
^crease intake over time. Finally, a six-year, large-scale, 
carefully conducted national survey showed that the great 
majority of physicians appropriately prescribe tranquilizers. 

Some people feel that patients being treated with anxiolytic 
drugs are "weak, " cant tolerate the anxieties of normal daily 
living, and should be able to resolve their problems on their 
own without the help of medication. 

The FACT is that while most people can withstand 
normal, everyday anxieties, some people experience 
excessive and persistent levels of anxiety due to personal or 
clinical problems. An extensive national survey concluded 
that Americans who do use tranquilizers have substantial 



r 



Racts 



justification as evidenced by tiieir high levels of anxiety. It 
was further noted that antianxiety drugs are not usually 
prescribed for trivial, transient emotional problems. 

Some people feel afraid of me because of the stories 
they've heard about my being harmful and having the 
potential to produce physical dependence. 

The FACT is that there are thousands of references in 
the medical literature documenting my efficacy and safety. 
Extensive and painstakingly thorough studies of toxicological 
data conclude that I am one of the safest types of psycho- 
tropic drugs available. Moreover, I do not cause physical 
dependence if the recommended dosage and therapeutic 
regimen are followed under careful physician supervision. 
However, I can produce dependence if patients do not fol- 
low their physicians directions and take me for prolonged 
periods, at dosages that exceed the therapeutic range. 
Patients for whom I have been prescribed should be cau- 
tious about their use of alcohol because an additive effect 
may result. 

Many of the most knowledgable people feel that I 
became the No. 1 prescribed medication in America because 
no other tranquilizer has been proven mx)re effective. Or safer. 

The FACT is they are right. 



For a brief summary of product information on Valium (diazepam /Roche) (iv . please see the following 
page. Valium is available as 2-mg, 5-mg and 10-mg scored tablets. 



Valium® 

diazepam/Roche 



Before prescribing, please consult complete 
product Information, a summary of which follows: 

Indications: Managemenl of anxiely disorders, or 
short-term relief of symptoms of anxiely, symptomatic 
relief of acute agitation, tremor, delirtum tremens and 
hallucinosis due lo acute alcohol withdrawal, adjunc- 
tively in skeletal muscle spasm due to reflex spasm 
to local pathology, spasticity caused by upper motor 
neuron disorders, athetosis, stiff-man syndrome; 
convulsive disorders (not for sole therapy) 
The effectiveness of Valium (diazepam/Roche) in long- 
term use. that is. more than 4 months, has no! been 
assessed by systematic clinical studies The physician 
should periodically reassess the usefulness of the drug 
for the individual patient 

Contralndlcated: Known hypersensitivity lo the drug. 
Children under 6 months of age Acute narrow angle 
glaucoma, may be used m patients with open angle 
glaucoma who are receiving appropriate therapy 
Warnings: Nol of value in psychotic patients Caution 
against hazardous occupations requiring complete 
mental alertness When used adjunctively in convulsive 
disorders, possibility of increase m frequency and/or 
severity of grand mal seizures may require increased 
dosage of standard anticonvulsant medication, abrupt 
withdrawal may be associated with temporary increase 
in frequency and/or seventy of seizures Advise against 
simultaneous ingestion of alcohol and other CNS de- 
pressants Withdrawal symptoms similar to those with 
barbiturates and alcohol have been observed with 
abrupt discontinuation, usually limited to extended use 
and excessive doses. Infrequently, milder withdrawal 
symptoms have been reported following abrupt discon- 
tinuation of benzodiazepines after continuous use, 
generally at higher therapeutic levels, for at least 
several months After extended therapy, gradually 
taper dosage Keep addiciion-prone individuals under 
careful surveillance because of their predisposition to 
habituation and dependence 

Usage In Pregnancy: Use of minor tranquil- 
izers during first trimester should almost 
always be avoided because of increased 
risk of congenital malformations as sug- 
gested In several studies. Consider 
possibility of pregnancy when instituting 
therapy; advise patients to discuss therapy 
if they intend to or do become pregnant. 
Precautions: it combined with other psychotropics or 
anticonvulsants, consider carefully pharmacology of 
agents employed, drugs such as phenothiazmes, 
narcotics, barbiturates, MAO inhibitors and other anti- 
depressants may potentiate its action Usual precau- 
tions indicated m patients severely depressed, or with 
latent depression, or with suicidal tendencies Observe 
usual precautions in impaired renal or hepatic function 
Limit dosage to smallest effective amoi-nt m elderly 
and debilitated to preclude ataxia or oversedation 
Side Effects: Drowsiness, contusion, diplopia, 
hypotension, changes m libido, nausea, fatigue, 
depression, dysarthria, jaundice, skin rash, ataxia, 
constipation, headache, incontinence, changes in 
salivation, slurred speech, tremor, vertigo, urinary 
retention, blurred vision Paradoxical reactions such as 
acute hyperexcited slates, anxiety, hallucinations, 
increased muscle spasticity, insomnia, rage, sleep 
disturbances, stimulation have been reported, should 
these occur, discontinue drug Isolated reports of 
neutropenia, jaundice, periodic blood counts and liver 
function tests advisable during long-term therapy 
Dosage: individualize for maximum beneficial effect 
Aaults Anxiety disorders, symptoms of anxiety, 2 to 10 
mg b I d to q i d . alcoholism, 10 mg t i d or q : d m 
first 24 hours, then 5 mg 1 i d or q i d as needed, 
adiunctively in skeletal muscle spasm. 2 to 10 mg t i d 
or q I d . adjunctively m convulsive disorders, 2 to 10 
mg b I d to q i d Geriatric or debilitated patients 2 to 
2^/2 mg, 1 or 2 times daily initially, increasing as 
needed and tolerated {See Precautions ) Children i to 
2'/2 mg t I d or q 1 d initially, increasing as needed 
and tolerated (not for use under 6 months) 
Supplied: Valium?- (diazepam/Roche) Tablets, 2 mg, 
5 mg and 10 mg— bottles of 100 and 500, Tel-E-DoseS 
packages of lOO, available m trays of 4 reverse-num- 
bered boxes of 25, and m boxes containing 10 strips 
of 10. Prescription Paks of 50. available m trays of 10 



Roche Laboratories 
' ROCHE y Division of Hoffmann-La Roche Inc 
Nutley, New Jersey 07110 






NORTH CAROLINA 
MEDICAL SOCIETY 
MEETINGS 




XOMMinEE CONCLAVE 
September 23-27, 1981 

Pines Club 
Southern Pines, N.C. 



ANNUAL MEETING 

May 6-9, 1982 

Pinehurst Hotel 
Pinehurst, N.C. 



Vol. 42. No. 7 



July 1981, Vol. 42, No. 7 



NORTH CAROLINA MEDICAL JOURNAL 

Published Monthly as the Official Organ of The North Carolina Medical Society (lsSN-0029-2559) 



STAFF 

John H. Felts, M.D. 
Winston-Salem 

EDITOR 

Mr. William N. Hilliard 
Raleigh 

BUSINESS MANAGER 



EDITORIAL BOARD 

Charles W. Styron, M.D. 
Raleigh 

CHAIRMAN 

George Johnson. Jr., M.D. 
Chapel Hill 

Edwin W. Monroe. M.D. 
Greenville 

Robert W. Prichard, M.D. 
Winston-Salem 

Rose Pully, M.D. 
Kinston 

Louis Shaffner, M.D. 
Winston-Salem 

Jay Arena. M.D. 
Durham 

Jack Hughes, M.D. 
Durham 



The appearance of an advertisement in this publication does not 
constitute any endorsement of the subject or claims of the 
advertisements. 

The Society is not to be considered as endorsing the views and 
opinions advanced by authors of papers delivered at the Annual 
Meeting or published in the official publication of the Society. 
— Constitution and Bylaws of the North Carolina Medical 
Society, Chapter IV. Section 4, page 4, 

NORTH CAROLINA MEDICAL JOURNAL, 300 S. Ha«'- 
thome Rd., Winston-Salem. N.C. 27103, is owned and pub- 
lished by The North Carolina Medical Society under the direc- 
tion of its Editorial Board. Copyright® The North Carolina 
Medical Society 1981. Address manuscripts and communica- 
tions regarding editorial matter to this Winston-Salem address. 
Questions relating to subscription rates, advertising, etc., 
should be addressed to the Business Manager, Box 27167, 
Raleigh, N.C. 27611. All advertisements are accepted subject 
to the approval of a screening committee of the State Medical 
Journal Advertising Bureau. 711 South Blvd., Oak Park, 
Illinois 60302 and/or by a Committee of the Editorial Board of 
the North Carolina Medical Journal in respect to strictly local 
advertising. Instructions to authors appear in the January and 
July issue. Annual Subscription, $12.00. Single copies. $2.00. 
Publication office: Edwards & Broughton Co. , P.O. Box 27286. 
Raleigh. N.C. 27611. Second-class postage paid at Raleigh. 
North Carolina 27611. 





Winchester Surgical Supply Company 

200 South TorrenceSt. Charlotte, N.C. 28204 
Phone No. 704-372-2240 
MEDICAL SUPPLY DIVISION FOR YOUR PATIENTS AT HOME 
1500 E. THIRD STREET Phone No. 704/332-1217 

Winchester-Ritch Surgical Company 

421 West Smith St. Greensboro, N.C. 27401 
Phone No. 919-273-5581 

Serving the MEDICAL PROFESSION of NORTH CAROUNA 
and SOUTH CAROUNA since 1919. 

We equip many new Doctors beginning practice each year, and invite your inquiries. 

Our salesmen are located in all parts of North Carolina 

We have DISPLAYED at every N.C. State Medical Society Meeting since 1921, and advertised 
CONTINUOUSLY in the N.C. Journal since January 1940 issue. 



MANDALA CENTER HOSPITAL 



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From time to time individuals may experience extreme problems in living. When this happens, it may 
become necessary to seek help from experienced members of the medical and helping professions. 
Mandala Center is an uncommon program dedicated to bringing to individuals an awareness of the 
source of their distress and help them find resolutions to their problems. 

Mandala Center is a JCAH accredited, private psychiatric hospital that specializes in the treatment of 
psychiatric illness, drug addiction, and alcoholism. The hospital was established in 1972 and is 
founded upon an interdisciplinary treatment approach. The 75-bed facility is located in Winston- 
Salem, NC, on a 15-acre site, and offers a full range of therapeutic modalities. Under medical 
supervision, the treatment team consists of psychiatrists, psychologists, pastoral counselors, social 
workers, psychiatric nurses, mental health workers and activities therapists. General medical care and 
special medical problems are provided for by the consulting staff. 

Adults and adolescents may enter the program which handles all categories of emotional and 
mental dysfunction. 




MEDICAL STAFF 

Bruce W. Rau. M.D., Medical Director 

Roger L. McCauley, M.D. 

Larry T. Burcfi, M.D. 

Edward H. Weaver, M.D. 

Robert W. Gibson. M.D. 

James Mattox, M.D. 

Ali Jarrahi, M.D, 

Selwyn Rose, M.D. 

Glenn N. Burgess. M.D. 



MANDALA CENTER, INC. 

3637 Old Vineyard Road 

Winston-Salem, N.C. 27104 

(919) 768-7710 



MEMBERSHIP IN: 

N.C. Hospital Association 
National Association of Private 

Psychiatric Hospitals 
Blue Cross Contracting Hospital 

Medicare, Medicaid approved 



For Information, please contact: 
Richard V. Woodard, Administrator 



Towards Wholeness 



Will an apple a day keep the doctor away? 




Apples alone won't do it. 
Good nutrition is an impor- 
tant part of staying healthy, 
but even a well-balanced diet 
can't guarantee that an unexpected 
accident or sickness won't happen to you. 
You can help keep your financial picture 
healthy by planning ahead for a time when 
you may be disabled and your income is 
disrupted. 

As a member of the North Carolina Medical 
Society, you are eligible to apply for Disability 
Income Protection for younger doctors. This 
plan can provide you with a regular monthly 
benefit when a covered sickness or injury 
keeps you from your practice. You can use 
your benefits any way you choose — to buy 
groceries, make house or car payments or 



provide for your children's 
education. 

If you're under the age of 55 and 
are active full time in your practice, 
simply fill out the coupon below and return 
it today. Mutual of Omaha, underwriter of 
this plan, will provide personal, courteous 
service in furnishing full details of coverage. 
Of course, there's no obligation. 



I Mutual of Omaha Insurance Company 

I Mutual of Omaha Plaza 

I Omaha, Nebraska 68175 

I Please provide me complete information on the Disability 

I Income Protection Plan available to members of the 

I North Carolina Medical Society who are under age 55. 

I 

I Name 



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Mutual 
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People i)ou can count on... 

Life Insurance Affiliate: United of Omaha 

Mutual of Omaha Insurance Company 

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Officers 
1981-1982 

NORTH CAROLINA MEDICAL 
SOCIETY 



President Josephine E. Newell. M.D. 

Raleigh Townes. Apt. 47. 525 Wade Ave.. Raleigh 27605 

Pre side nt-Elect Marshall S. Redding. M.D. 

1142 N. Road St., Elizabeth City 27909 

First Vice-President John W. Foust. M.D. 

3535 Randolph Rd., Charlotte 28222 

Second Vice-President Emery C. Miller. Jr.. M.D. 

Bowman Gray. Winston-Salem 27103 

Secretary Jack Hughes. M.D. 

923 Broad St.. Durham 27705 (1982) 

Speaker Henry J. Carr. Jr.. M.D. 

603 Beaman St.. Clinton 28328 

Vice-Speaker T. Reginald Harris. M.D. 

808 Schenck St.. Shelby 28150 

Past-President Frank Sohmer. M.D. 

2240 Cloverdale Ave.. Ste. 88, Winston-Salem 27103 

Executive Director William N. Hilliard 

222 N. Person St., Raleigh 27611 



Councilors and Vice-Councilors — 1981-1982 



M.D. 



M.D. 
M.D. 
M.D. 
M.D. 



First District Robert E. Lane, 

Chowan Med. Ctr., Edenton 27932 (1983) 

Vice-Councilor James M. Watson, M.D. 

1134 N. Road St., Elizabeth City 27909 (1983) 

Second District Charles P. Nicholson, Jr.. M.D. 

3108 Arendell St., Morehead City 28557 (1982) 

Vice-Councilor Alfred L. Ferguson, M.D. 

6 Doctors Park, Stantonsburg Rd.. Greenville 27834 (1982) 

Third District R. Bertram Williams, Jr., M.D. 

1414 Medical Center Dr., Wilmington 28401 (1982) 

Vice-Councilor Charles L. Garrett. Jr.. M.D. 

P.O. Box 1358. Jacksonville 28540 (1982) 

Fourth District Robert H. Shackelford. 

238 Smith Chapel Rd., Mt. Olive 28365 (1983) 

Vice-Councilor Lawrence M. Cutchin. Jr. 

P.O. Bo.x 40. Tarboro 27886 (1983) 

Fifth District Bruce B. Blackmon. 

P.O. Box 8, Buies Creek 27506 (1984) 

Vice-Councilor Giles L. Cloninger. Jr.. 

115 Main St., Hamlet 28345 (1984) 

Sixth District W. Beverly Tucker. M.D. 

Ruin Creek Rd.. Henderson 27536 (1983) 

Vice-Councilor C. Glenn Pickard, Jr., M.D. 

N.C. Memorial Hospital, Chapel Hill 27514 (19831 

Seventh District James B. Greenwood, Jr., M.D. 

4101 Central Avenue. Charlotte 28205 (1984) 

Vice-Councilor Thomas L. Dulin. M.D. 

P.O. Box 220892. Charlotte 28222 (1984) 

Eighth District Shahane R. Taylor. Jr., M.D. 

348 N. Elm St.. Greensboro 27401 (1982) 

Vice-Councilor L Gordon Early. M.D. 

2240 Cloverdale Ave.. Ste. 192. Winston-Salem 27103 (1982) 

Ninth District Jack C. Evans. M.D. 

244 Fairview Dr., Lexington 27292 (1982) 

Vice-Councilor Benjamin W. Goodman, M.D. 

24 Second Ave.. N.E.. Hickory 28601 (1982) 

Tenth District Charles T. McCullough, Jr., M.D. 

Bone & Joint Clinic. Doctors Dr., Asheville 28801 (1984) 

Vice-Councilor George W. Brown, M.D. 

102 Brown Ave., Hazelwood 28738 (1984) 



Section Chairmen - 

Allergy & Clinical Immunology . . . 



1981-1982 



Anesthesiology J. LeRoy King, M.D. 

3600 New Bern Ave., Raleigh 27610 

Dermatology Charles E. Cummings, M.D. 

281 McDowell Street. Asheville 28803 

Emergency Medicine 

Family Practice Hal M. Stuart, M.D. 

180-C Parkwood Dr.. Elkin 28621 

Internal Medicine William R. Bullock, M.D. 

217 Travis Avenue, Charlotte 28204 

Neurological Surgery Robert E. Price. Jr., M.D. 

1830 Hillandale Rd., Durham 27705 

Neurology & Psychiatry Assad Meymandi, M.D. 

1212 "Walter Reed Road. Fayetteville 28304 

Nuclear Medicine William McCartney. M.D. 

N.C. Memorial Hosp.. Dept. of Nuclear Medicine, 
Chapel Hill 27514 

Obstetrics & Gynecology Talbot E. Parker, Jr., M.D. 

2400 Wayne Memorial Drive, Ste. K, Goldsboro 27530 

Ophthalmology J. Lawrence Sippe. M.D. 

1350 S. Kings Drive. Chariotte 28207 

Orthopaedics Richard N. Wrenn, M.D. 

1822 Brunswick Avenue, Charlotte 28207 
Otolaryngology & Maxillofacial 

Surgery Walter R. Sabiston. M.D. 

400 Glenwood Ave.. Kinston 28501 

Pathology Ron Edwards, M.D. 

3000 New Bern Ave.. Raleigh 27610 

Pediatrics DavidT. Tayloe, M.D. 

608 E. 12th St.. Washington 27889 
Plastic & Reconstructive 

Surgery Andrew W. Walker. M.D. 

2215 Randolph Rd.. Charlotte 28207 

Public Health & Education Verna Y. Barefoot. M.D. 

2504 Old Cherry Point Rd.. New Bern 28560 

Radiology Luther E. Earnhardt. Jr.. M.D. 

Executive Park. Ste. 203. Asheville 28801 

Surgery Carl A. Sardj. M.D. 

Climax 27233 

Urology Donald T. Lucey. M.D. 

P.O. Box 17908. Raleigh 27619 

Delegates to the American Medical Association 

James E. Davis, M.D.. 2609 N. Duke St.. Ste. 402. Durham 27704 

— 2-year term (January 1. 1981-December 31. 1982) 
John Glasson. M.D. .2609 N. Duke St. .Ste. 301. Durham 27704 — 

2-year term (January 1. 1981-December 31. 1982) 
David G. Welton. M.D.. 3535 Randolph Rd.. 101-W. Charlotte 

28211 — 2-year term (January 1. 1980-December 31. 1981) 
Frank R. Reynolds. M.D.. 1613 Dock St.. Wilmington 28401 — 

2-year term (January 1. 1981-December 31. 19821 
Louis deS. Shaffner. M.D.. Bowman Gray. Winston-Salem 

27103 — 2-year term (January 1. 1980-December 31. 1981) 

Alternates to the .American Medical Association 

E. Harvey Estes. Jr.. M.D.. Duke Med. Ctr.. Box 2914, Durham 
27710 — 2-year term (January 1, 1981-December 31 , 1982) 

Charles W. Styron, M.D.. 615 St. Mary's St., Raleigh 27605 — 
2-year term (January 1. 1980-December 31 . 1981) 

D. E. Ward. Jr., M.D.. 2604 N. Elm St.. Lumberton 28358 — 
2-year term (January 1, 1980-December 31, 1981) 

Jesse Caldwell, Jr., M.D., 1307 Park Lane. Gastonia 28052 — 
2-year term (January 1. 1981-December 31, 1982) 

Frank Sohmer, M.D., 2240 Cloverdale Ave.. Ste. 88, Winston- 
Salem 27103— 2-year term (January 1, 1981-December31, 1982) 



448 



Vol. 42, No. 7 



WHEN YOU THINK OFaDISABILITY— 

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REASON — the broadest coverage at the lowest premium scale — 

Recently reduced rates for members under age 50 by virtue of Society sponsorship and 
high participation of members. 

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No medical exam required nor restriction of benefit due to other coverage! 
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PAIN AND TENSIO 

Double fault for 
weekend warrion 




Equagesic*® 

(meprobamate and ethoheptazine citrate with aspirin) Wyeth 

Twofold analgesic action teamed with time-proven efficacy against 
concurrent anxiety and tension in patients with musculoskeletal disease* 



- EQUAGESIC— Abbreviated Summary 



•INDICATIONS; Based or a review of this drug by the 
Nal'onai Academy ot Sciences— National Researcti 
Counai and o' other intormatton FDA has ciass^ied 
the irdications as follows 

"Possibly' efleclrve for ihe Irealment of pam accom- 
panied by tension ana of anxiety m patients with mus- 
culoskeletal disease or lension headache. 
Final ciassrticaDon o' the less-than-eMective indicaikins 
requires further investigation 

The effectiveness of Equagesic m long-term use. < e 
more than lour monihs has mil been assessed by sys- 
tematic clinical studies The ohysoan should penoOi- 
cally reassess usefulness of the drug tc the moivKjuai 
patient 



CONTRAINDICATIONS: Equagesic shouW nol be given to 
individuals wilh a history of sensitivity or severe intolerance 
loaspinn meprobamaie or ethoheptazine curate 
WARNINGS: Careful supervision ot dose and amounts pre- 
scribed for patients IS advised especially with those patients 
with known propensity for taking excessive quantities of drugs 
Excessive and prolonged use in susceptible persons, e g . 
alcoholics, fomier addicts, and other sevefe psychoneurot- 
ics, has been reported lo result m dependence on or habn- 
ualion lo the drug Where excessive dosage has contmued 
lof weeks or months, dosage should be reduced gradually 
rather than abruptly slopped, since withdrawal of a crotch' 
may preciprtate withdrawal reaction of greater proportions 
than that 'or which the drug was originally prescnbed Abrupt 
discontinuance of doses m excess of the recommended dose 
has resulted m some cases in the occurrence of epileptiform 
seizures 

Special care should tie taken to warn patients taking mepro- 
bamate thai tolerance to alcohol may be lowered vnth result- 
art slowing of reaction time and impairment of ludgment and 
ccwrdination 

USAGE IN PREGNANCY AND LACTATION: An increased 
risk at cor>genital malformations associated with the use 



ot minor Iranquilizers (meprobamate. chlordiazepoxide. 
and diazepam) during the firs! trimester of pregnancy 
has been suggested in several studies. Because use of 
these drugs is rarely a matter ot urgency, their use dur- 
ing this period should almost always be avoided The 
possibility that a woman ot child-bearing potential may 
be pregnant at the time of institution of therapy should 
be considered Patients should be advised that il they 
become pregnant during therapy or intend to become 
pregnant they should communicate with their physi- 
cians about the desirability ot discontinuing the drug 
Meprobamaie passes the placental barrier It is present 
both in umbilical-cord blood al or near maternal plasma 
levels and m breast milk of lactalmg mothers al concen- 
trations two to four times that of maternal plasma. When 
use of meprobamate <s contemplated m breast-feeding 
patients, the drug s higher concentration in breast milk 
as compared to maternal plasma levels should be 
considered. 

Preparations containing aspinn should be kept out of the 
reach of chikjren Equagesic is not recommended lor pa- 
tients 12 years of age and uryler 

PRECAUTIONS: Should drowsiness ataxia, or visual distur- 
bance occur the dose sfrould t>e reduced II symptoms con- 
tinue, patients should not operate a motor vehicle or any 
dangerous machinery 

Suicidal attempts with meprobamate have resulted m coma, 
shock, vasomotor and respiratory collapse, and anuna Very 
lew suicidal attempts were fatal although some patients in- 
gested very large amounts of the drug |20 to 10 gm) These 
doses are much greater than recommended The drug should 
De given cautiobsly and m small amounts to patients who 
have suiadai tendencies In cases where excessive doses 
have been taken sleep ensues rapidly and blood pressure 
pulse and respiratory rales are reduced to basal levels Hy- 
perventilation has been reported occasionally Any drug re- 
maining in the stomach should be removed and symptomatic 
treatment given Should respiration become very shallow ana 
slow. CNS stimulams eg caffeine. Metrazol. or ampheta- 



mine, mav be cautiously administered II severe hypotension 
develops, pressor amines should be used oarenieialty to re- 
store blood oressure lo normal levels 

ADVERSE REACTIONS: A small percentage pf patients 
may expeience nausea with or without vomiting and epigas- 
tric distress Dizziness occurs rarely when meprotiamate and 
ethoheptazine citrate with aspinn is administered in recom- 
mended dosage The meprobamate may cause drowsmess 
bul as a "uie this disappears as therapy is continued ShouW 
drowsiness persist and Be associated witfi ataxia this symp- 
tom can usually Oe controlled by decreasing the dose but 
occasionally H may be desirable to administer central stimu- 
lants such as amphetamine or mepheniermme sulfate con- 
comitanlty to control drowsiness 

A clearly related side effea to the administration of mepro- 
bamate IS the rare occurrence of allergic or idiosyncratic re- 
actions This response devekDos as a rule m patients who 
have had only 1-4 doses of meprobamaie and have rxjt had 
a previous contact with the drug Previous history of allergy 
may or may nol be related lo the incidence ot reactions 
MiW reactions are charactenzed by an itchy urticarial or ery- 
thematous, maculopapuiar rash which may be generalized 
or confined 10 the groin Acute nonthrombocytopenic purpura 
with cutaneous petechiae ecchymoses penpherai edema 
and fever have also been reported 

More severe cases observed only very rarely may also have 
Other allergic responses including lever famting spells an- 
gioneurotic edema, bronchial spasms, hypotensive crises (1 
fatal case), anaphylaxis, slomatilis and pioctitis n case) and 
hyperthermia Treatment should be symptomatic such as 
administration of epinephnne. antihistamine, and possibly 
hydrocortisone Meprobamate should be stopped, and rem- 
stitution of therapy should nol be attempted 
Rare cases have been reponed where patients receiving me- 
probamate suffered from aplastic anemia |i fatal easel 
thrombocytopenic purpura, agranulocytosis and hemolytic 
anemia In nearly every instance reported other toxic agents 
known lo have caused these conditions have tjeen associ- 
aied with meprobamaie A lew cases of leukopenia dunng 



continuous administratHXt of meprobamate are reported mosl 
of these returned to normal without discontinuation of the 
drug 

Impairment of accommodation and visual acuity has been 
reported rarely 

OVERDOSE: Two instances of accidental or intentional Sig- 
nificant overdosage with ethcrfiepiazme citrate combined v^ith 
aspinn have been reported These were accompanied by 
symptoms of CNS depression, including d'owsmess and light- 
headedness, with unevenftul recovery Howeve' on the basis 
of pharmacological data, n may t>e antiopaied thai CNS stim- 
ulation could occur. Other anticipated symptoms would in- 
clude nausea and vomiting Appropnaie therapy of signs and 
symptoms as they appear is the only recommendation pos- 
sible al this lime Overdosage with ettioheptazine combined 
with aspinn v^ould probably producetheusualsymptomsand 
Signs of salicylate inioxicaDon Observation and treatmenl 
should include induced vomiting or gastric lavage specific 
paienteral electrolyte therapy for ketoaadosis and dehydra- 
tion watching for evidence of hemorrhagic manifestations 
due to hypopfolhrombinemia which if il occurs, usually re- 
quires whole-blood transfusions 

DESCRIPTION: Each Equagesic lablel contains 150 n^ me- 
probamate 75 mg ethoheptazine citrate and 250 mg aspirin 

Copyright c 1981, ViTyeth Laboratories 
All rights reserved, 

"This drug has been evaluated as possibly 
eHeci've tor this indication 

Wyeth Laboratories 

' ' Philadelphia. PA 19101 



\JA 




for mild to moderate pain 

Wygesic® 



(65 mg propoxyphene HCI and 650 mg acetaminophen) Wyeth 

More than twice as much acetaminophen as the leading combination plus a full 
therapeutic dose of propoxyphene... all in a convenient, economical single tablet. 



WYGESIC— Abbreviated Summary 

INDICATION (-LT ihe 'eliel ol mildlo-moderaie pain 
CONTRAiNDICATION: Hypersensitivily to propox- 

■,; '■■ • ;■ ' .1 ■ 'aminophen 

WARNINGS. ::ns additive effects and over- 
dosage Propoxyphene in comtiination with alcohol 
tranquilizers, sedative-dypnolics or other CNS de- 
ptessants has an additive depressant eltect Pa- 
lienis taking this drug should De advised of the additive 
ellecl and warned not to exceed the dosage recom- 
mended Toxic elfecls and fatalities have occurred 
(ollowing overdoses of propoxyphene alone or m 
combination with other CNS depressants fVlosI ol 
these patients had histories of emotional disturb- 
ances or suicidal ideation or aitempis. as well as 
misuse ot tranquilizers, alcohol, or other CNS-aclive 
drugs Caution should be exercised m prescribing 
large amounts of pfopoxyphene lor such patients 
(see Management of Overdosage) 
DRUG DEPENDENCE: Propoxyphene can produce 
drug dependence characterized by psychic depend- 
ence and less frequently, physical dependence and 
tolerance It will only partially suppress the with- 
drawal syndrome m individuals physically dependent 
on morphine o' other narcotics The abuse liability o' 
propoxyphene is qualitatively similar to codeines al- 
though quantitatively less, and propoxyphene should 
be prescribed with the same degree ol caution ap- 
propriate to the use ol codeme 

USAGE IN AMBULATORY PATIENTS: Propoxy- 
phene may impair the mental and/or physical abilities 
required lor potentially hazardous lasKs, e g driving 
a cat or operating machinery Patients should be 
cautioned accordingly 

USAGE IN PREGNANCY: Sale use m pregnancy 
has not been established relative to possible ad- 
verse eiiecis on fetal development INSTANCES OF 
WITHDRAWAL SYMPTOfulS IN THE NEONATE 
HAVE BEEN REPORTED FOLLOWING USAGE 
DURING PREGNANCY Therefore propoxyphene 
should not be used m pregnant women unless, in the 



judgement ol the physician, the potential benefits 
outweigh the possible hazards 

USAGE IN CHILDREN: Propoxyphene is not rec- 
ommended lor children because documented clinical 
experience has been msulliciert to establish salety 
and a suitable dosage regimen m the pediatric group 
PRECAUTIONS: Conlusion, anxiety, and tremors 
have been reported m a lew patients receiving pfo- 
poxyphene concomitantly with orphenadnne The CNS 
depressant effect ot propoxyphene may be additive 
with other CNS depressants, including alcohol 
ADVERSE REACTIONS: The most frequent ad- 
verse reactions are dizziness sedation nausea and 
vomilmg These seem more prominent m ambulatory 
than in nonambulatory patients some of Ihese re- 
actions may be alleviated if the patient lies down 
Other adverse reactions include constipation, ab- 
dominal pain skin rashes hghi-headedness head- 
ache weakness euphoria dysphoria, and minor 
visual disturbances The chronic ingestion ol propox- 
yphene m doses over 800 mg per day has caused 
loxic psychoses and convulsions Cases of liver dys- 
function have been reported 

DRUG INTERACTIONS: Propoxyphene in combi- 
nation with alcohol tranquilizers, sedative-hypnot- 
ics, and other CNS depressants has an additive 
depressant effect Patients tahmg this drug should 
be advised ol the additive effect and warned not to 
exceed the dosage recommended isee Warnings) 
Confusion anxiety and tremors have beer) reponed 
in a few patients receiving propoxyphene concomi- 
tantly with orphenadnne 

MANAGEMENT OF OVERDOSAGE: SYMPTOtwS 
The •■nanilesialions of serious overdosage with pro- 
poxyphene are similar to those of narcotic overdos- 
age and include respiratory depression (a decrease 
m respiratory rale and or tidal volume, Cheyne- 
Stokes respiration, cyanosis), extreme somnolence 
progressing to Stupor or coma. pupillary constriction, 
and circulatory collapse In addition to these char- 
acteristics, which are reversed by narcotic antago- 



nists Such as naloxone there may be other effects 
Overdoses of propoxyphene can cause delay ol car- 
diac conduction as well as local or generalized con- 
vulsions, a prominent feature m most cases ol severe 
poisoning Cardiac arrhythmias and pulmonary edema 
have occasionally been reported, and apnea car- 
diac arrest, and death have occurred 
Symptoms ol massive overdosage wilh acetamino- 
phen may include nausea, vomiting anorexia, and 
abdominal pam beginning shortly after ingestion and 
lasting for 12 to 24 hours However early recognition 
may be difiicult smce eariy symptoms may be mild 
and nonspecific Evidence ol iiver damage is usually 
delayed Alter the initial symptoms the patient may 
leel less ill, however laboratory determinations are 
likely to show a rapid nse m hver enzymes and bili- 
rubin In case ol senous hepatotoxicily, jaundice, co- 
agulation defects, hypoglycemia, encephalopathy, 
coma and death may follow Renal failure due to 
tubular necrosis, and myocardiopathy, have also been 
reported 

Ingestion of 10 grams or more of acetaminophen 
may produce hepatoloxicity A 13-gram dose has re- 
portedly been fatal 

TREATMENT: Primary attention should be given to 
the reestabiishment of adequate respiratory ex- 
change through provision ot a patent airway and in- 
stitution of assisted or controlled ventilation The 
narcotic antagonists naloxone nalorphine and lev- 
allorphan are specific antidotes against the respira- 
tory depression produced by propoxyphene An 
appropriate dose of one of these antagonists should 
be administered preferably I V .simultaneously with el - 
forts at respiratory resuscitation and the antagonist 
should be repeated as necessary until the patients 
condition remains satislactory In addition to a nar- 
cotic antagonist the patient may require carelui tilra- 
lion with an anticonvulsant to control seizures 
Analeptic drugs (e g caffeine or amphetammei should 
not be used because ol their tendency to precipitate 
convulsions 



Oxygen IV lluids vasopressors and other suppor- 
tive measures should be used as indicated Gaslnc 
lavage may be helpful Activated charcoal can ab- 
sorb a signilicant amount of ingested propoxyphene 
Dialysis is of little value m poisoning by propoxy- 
phene alone Acetaminophen is rapidly absorbed 
and efforts to remove the drug (rem the body should 
not be delayed Copious gastric lavage and or induc- 
tion of emesis may be indicated Activated charcoal 
is probably ineffective unless administered almost 
immediately alter acetaminophen ingestion Neither 
forced diuresis nor hemodialysis appears lo be ef- 
fective m removing acetaminophen Smce acetami- 
nophen in Overdose may have an antidiureltc effect 
and may produce renal damage administration of 
fluids should be carefully monitored to avoid over- 
load It has been reported that mercaptamme (cys- 
leamme) or other thiol compounds may protect against 
hver damage if given soon after overdosage (8-10 
hours) N-acetylcysteme is under investigation as a 
less toxic alternative lo mercaptamme, which may 
cause anorexia, nausea, vomiting, and drowsiness 
Appropriate literature should be consulted lor further 
inlormation (JAMA 237 2406-2407, 1977) 
Clinical and laboratory evidence of hepatotoxicity may 
be delayed up to one week Acetaminophen plasma 
levels and half-life may be useful m assessing the 
likelihood of hepatotoxicity Serial hepatic enzyme 
determinations are also recommended 

Copyright e 1981, Wyeth Laboratories- 
All rights reserved 

Wyeth Laboratories 

' •" - Philadelphia, PA 19101 



M 



i 



A^ 






%. 















KjJUTQMOIi] 






As a physician or medical student, you automatically have a 
strong vested interest in medical ethics. Ethics are a 
traditional frame of reference for society's attitude toward 
physicians. Today in America, there is more reference to that 
frame than ever before. 

That's because so many of today's health-care issues are 
ethical challenges. As outstanding examples, consider the 
moral right and wrong involved in: 

• Seemingly excessive or needless costs of medical 
services — at a time when cost is the chief health-care issue 
and the chief basis for government intervention in care. 

• Medicine's enhanced ability and obligation to prolong the 
lives of the terminally ill — versus pressures for mercy killing 
and for limits on the expenditure of health-care resources. 

• Rules and procedures that could make medical records 
more accessible to outsiders. The moral conflict here is 
between the principles of confidentiality and the stake of third 
parties (notably government) in medical oversight and review. 

• The question as to where various biomedical advances, 
such as genetic engineering and test-tube fertilization will 
lead us? 



Those and similar questions involve the very character of 



medical practice, including your own. Ethically wrong 
answers could distort that character. 

Physicians have to do their best to provide answers that are 
both high-minded and sure-footed. Acting in concert, we have 
to come forth with sound ethical principles and applications. 

The AMA has stood for traditional moral values from its very 
beginnings but has been flexible enough to keep adapting to 
new needs. In order to adapt, the AMA (by vote of its House 
of Delegates) revised its Principles of Medical Ethics last 
July — the fifth time it has done so. 

Here are some of the ways in which the AMA has been apply- 
ing medical ethics to relevant current issues ... on your 
behalf: 

• Stimulation of ways to cut down on needless or excessive 
health services and costs. This includes peer and utilization 
review, physician participation in PSROs, cost-benefit 
analysis, and alternatives to hospitalization whenever feasible. 

• Model state legislation for disciplining the wayward or 
incompetent physician, who can be an economic as well as a 
medical problem. Twenty-three states now have laws that 
wholly or partially resemble the AMA model. 

• New ethical standards on such topics as genetic 
engineering, test-tube fertilization, and euthanasia ... as set 
forth in the latest edition of the AMA Judicial Council Opinions 
and Reports. 

• Tireless legislative and legal efforts to protect the 
confidentiality of patient records. 

• To maximize our effectiveness, we need YOUR 
MEMBERSHIP. The larger our membership (230,000 now), the 
bigger our influence. We need influence in coordinating the 
ethical commitment of American medicine . . . and in clarify- 
ing that commitment to government, to society, and 
throughout our profession. 

We need YOU ... if we're to give you all the help that you 
need. 



For details on how to join, contact your state or county 
medical society or the Office of Membership Develop- 
ment, American Medical Association, 535 N. Dearborn, 
Chicago, IL 60610 (312) 751-6410. 



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REFERRING YOUR PATIENTS 

FOR SPECIAL TREATMENT TO 

DURHAM — THE CITY OF MEDICINE 



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We are convenient to Duke Medical Center, V.A. Hospital and McPherson's Hospital. We 
offer free transportation to the hospitals every hour between the hours of 8:00 a.m. and 
6:00p.m. Transportation after 6:00 p.m. by special request only . Via our free van service , 
we are only 7 to 8 minutes away and your parking problems are solved. 

We offer friendly, courteous service to all our guests. So often the special needs of patients 
and their families might be overlooked. We pride ourselves on our reputation for caring 
about the individuals who make the Ramada Inn Downtown their temporary home during 
their stay in Durham. 



159 tastefully decorated rooms 

Indoor heated pool 

Sauna 

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Whirlpool 

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Lounge 

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10% discount after 30 days 

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Acute pain 

is no laughing matter. 

The first prescription for 
the first days of acute pain 

Empirinc Codeine #3 

For the millions of patients who need the potency 
of aspirin and codeine for their acute pain 

The pain of fractures, strains, sprains, burns and 
wounds IS at its peak during the first three to four days 
following trauma. The potent action of Empirin c 
Codeine begins to work within 15 minutes of oral ad- 
ministration, an important advantage during this acute 
pain period. Empirin c Codeine has unique bi-level 
action to attack pain at two critical points: peripherally 
at the site of injury and centrally at the site of pain 
awareness. ^ 

For the most effective dosage in treating acute pain 
begin with . . two tablets of Empirin c Codeine #2 or 
#X every four hours. Titrate downward as pain sub- 



EMPIRIN® with Codeine 




LONTRAINDICATIONS: Hypersensitivity to aspirin or codeine 
WARNINGS: 

tion ol this drug and it stiould be prescribed and adm n,^ pr,S 2 fb . ?^ ''^^''"' ""'" ""^'^ administra- 

oral narcotic-containing medicat ons the na n^ „,t ^^' "t^"' ! 'f '"" """"""'' *» "" "» »* o'"^' 

trolled Substances Act narcotic-containing medications, the drug is subject to the Federal Con- 

X^sizsx,^r;^::t^ti:ra'r::^r:!3?s^ 

be cautioned accordingly. ^ operating machinery. The patient using this drug should 

tantly with Empirin mth Codeine may exhibi an adSe « 3enr«s „ m "IsPfessants (including alcohol) concomi- 
dose of one or both agents should be reduced ' ™'" '"'" """"""' '""'P' '^ contemplated, the 

benefits outweigh the possible hazards '^'' '" ""= I"*"""' »' ">= P'^sician, the potential 

PRECAUTIONS: 

elS^cSr^stSird'prersu^ry'heS^e:^^^^^^^^^^ ff '-' -™'- -- >'^^" ^P^cit, to 

3 pre.e.,st,ng increase m intracranial p essu FurtSo co tc orndr t "" '"'"T """^ '"'""^'"'' '=='°"^ "' 
clinical course ol patients wilh head injunes """"'■ "'™''" P""*"":' ^^e'^e reactions which may obscure the 

Sf aie'St^^forhrpe^^Sitl^trsp,™"' ""^'"" '° "'™"^ ™'^ ^""^ ="-«'- P^'i-'^ "'^ -sa, 

S;ale?*n51£w^;:^^,:t^Sr:a?^nn"'? -•■"V'^f™ '"'^'^ ^^ ^ '^ ^*'^ »' 
Viropby or urethral stricture, peptirrefor LStioLisorte "' ^'P"*^'™*^™' W"™'^ *««*■ P^P^^tic 

«da"on^a"?afd«tn^TheSLtmTbe1:rorl'*^ '° ff" ™'"* "^^'-^--^-s.. dimness, 
'.some of these adverse reactfons miy be a S^ f th e aS I e dn^'t'"^ *!'" '" ""'"""""p^ P'-'e"ts and 
dysphoria, constipation, and pruritus, "*" "*" ^''™'^" '«="'°"s include aiiphorla, 

S-Pe patients are unable to take sa"icy5at«,L?dS»i„';s?,1X2f ?."«''''''''"-.'"'* "^"""^ """ '^P""" 

n°a°iif«'""' *™INISTBAriON: Dosage should be adjusted according to the se. -v 

inos^at.ents who have become loleiant to the analgesic effect of narcotics fr-- 

ror tn^inn wlB CoJems No 4 IS one tablet every tout hours 3S required " ' 

ORUe INTERACTIONS: The CNS depressant 
effects of Empirin with Codeine may be 

^dditive Kit-h that of other CfC depressants 

'="*W«5 Vifeii^el 



adult iose for 
.■^..^ tor Er^inn v, 

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NORTH CAROLINA MEDICAL SOCIETY 
APPROVED INSURANCE PROGRAMS 

Major Hospital and Nurse Expense Insurance 

$25,000 maximum benefit: choice of deductibles from $100 to $1,000: benefits 
paid regardless of other insurance 

In Hospital Indemnity Insurance 

Benefits available from $30 to $75 per day: pays regardless of other insurance 

Excess Major Medical Insurance 

$250,000 maximum: choice of $15,000 or $25,000 deductible 

Term Life Insurance 

Coverage from $10,000 to $100,000: dependents and employees eligible 

Business Overhead Expense Insurance 

Monthly benefits from $200 to $3,000 per month : benefits payable after 31 days 
of disability retroactive to the first day of disability: benefits payable up to 1 2 
consecutive months: premiums are tax deductible as a business expense 

Each of the above plans may qualify for use by professional corporations. 

We have been working with physicians in North Carolina for more than 40 
years. 



WRITE OR CALL FOR FURTHER INFORMATION 

GOLDEN-BRABHAM INSURANCE AGENCY, INC. 

108 East Northwood St., P.O. Drawer 6395 

Across Street from Cone Hospital 

Greensboro, N.C. 27405 

Tel: (919) 2753400 or 275-5035 




PRESIDENT'S NEWSLETTER 

NORTH CAROLINA MEDICAL SOCIETY 



NO. 



JULY 1981 



Dear Colleagues: 

We returned from Chicago VICTORIOUS. Jim Davis was elected to the office of 
Vice-Speaker of the American Medical Association. As Vice-Speaker, Jim will sit 
with the Board of Trustees and, although without vote, may be able to impact 
policy decisions of the Board in a major way. We wish him every success and are 
confident that Jim, in his usual manner, will make every effort to be the best 
Vice-Speaker that the AMA has ever known. 

In other actions, the AMA upheld its previous stand in opposition to both PSRO 
and HSA. In Reports A and B, the Council on Medical Services sets forth guide- 
lines for regional, voluntary health planning. Most physicians agree that we 
support both voluntary peer review and voluntary health planning which is physi- 
cian directed. 

Representative Wilma Woodard, a steadfast friend of the North Carolina Medical 
Society and Chairman of the House Committee on Corrections, requested that a 
North Carolina Medical Society Committee to Investigate Grievances Relative to 
Medical Care of Prison Residents be appointed. You may remember that a previous 
study was done in 1975, during the Holshouser administration. The excellent 
report of this previous committee composed of Dr. Philip Nelson, Rose Pully, and 
George Debnam brought about some improvements. We were asked that the Committee 
represent certain specialties throughout the entire state. Past-President Jesse 
Caldwell, Jr., has agreed to chair this committee which is composed as follows: 

Jesse Caldwell, Jr., M.D., Chairman, OB-GYN, Gastonia 
John A. Ewing, M.D., Psychiatry, Drug Abuse, Chapel Hill 
George C. Debnam, M.D. , General Practice, Raleigh 
Philip G. Nelson, M.D., Psychiatry, Greenville 
Rose Pully, M.D., Family Practice, Kinston 
George G. Gilbert, M.D., Urology, Asheville 
William B. Wood, M.D., Pulmonary Disease, Chapel Hill 
Susan S. Gustke, M.D., Internal Medicine, Raleigh 

At a press conference on June 17, Representative Woodard (D, Wake County), 
announced the two year study. I am so grateful that this fine, conscientious 
group of physicians has agreed to accept this responsibility, which will require 
both time and endeavor. 



Don Chaplin, Chairman of the Committee on Legislation, has exciting plans for the 
coming year. Mark your calendar for the weekend of October 30, 31, and November 1- 
the dates of the Legislative Symposium at Myrtle Beach. It will be a weekend of 
interest, education and fun. Your personal involvement is extremely important to 
your future and the future of the North Carolina Medical Society. Please plan to 
participate! If you don't become involved, don't complain about what bureaucracy 
is doing to medicine! Deal with it on a one-to-one basis! Try to bring one of 
your own Legislators. We promise you a good opportunity to learn and to voice 
your own opinions. 



As you are aware, the North Carolina Medical Society and the North Carolina Society 
of Ophthalmology are vigorously seeking legislative action to repeal the Optometry 
Drug Use Law. Our ophthalmologists have gathered together many cases of mis- 
diagnoses by optometrists, with serious sequelae, and produced an excellent packet ' 
of these cases for the Legislators. They have supported their belief that this M 
law must be repealed with their money, minds, and hearts. I was privileged to be W 
with them at the bill's hearing before the Senate Health Committee and was so 
impressed with their business-like sincerity that I wish each of you could have \\ 
been with us. Their lobbyist had six of us to meet at the Headquarters for a 1 
practice hearing before we marched to the Legislative Building for the actual t 
hearing, which was well received by the Senate Health Committee. Vote in Committee 
is scheduled for Tuesday, June 2-3 (after three postponements). I am sure that 
there is no need to remind our ophthalmological colleagues that we wish them well 

and recognize that they have fought long and well not only for themselves but 

for all of medicine! 



/ 



On June 17, 1981, the Committee on Health Planning and Development met at the 
Headquarters Office. Although a quorum was not present. Chairman Bill Laupus went 
on with the business at hand because of its urgency. With the apparent gratitude 
of the American Medical Association, the new Department of Health and Human Ser- 
vices has indicated an early demise for federal health planning and HSA's, as we 
know them. We are well advised that some form of health planning will be in its 
place. The House of Delegates of the AMA, by adopting Report A of the Council on 
Medical Services, has endorsed the concept of voluntary, local health planning. 
Since our committee was created and charged with the responsibility to monitor 
HSA's, now its direction, as well as its charge must change. We need your advice 
and opinions on this matter of grave importance. Please let us hear from you 
immediately! Both the North Carolina Medical Society and the American Medical 
Association have endorsed repeal of P.L. 93-641, The Health Planning Act. 



i 



I 



Don Chaplin, Joe Russell, John McCain, Charles Hoffman, and I visited with .Sarah 
Morrow (Secretary, Department of Human Resources) on Thursday, June 18, 1981. 
After an hour of friendly and fruitful discussion of our shared problems. Dr. Morro* 
and Barbara D. Matula (Director, Division of Medical Assistance) joined us for a \\ 
similar discussion with Governor James B. Hunt, Jr. We were graciously received 
by Governor Hunt who seemed quite pleased to visit with us, as representatives of ; 
the North Carolina Medical Society. He reminded us of federal cuts in all health 
delivery budgets and assured us of a seat at decision making tables. mi 

I 
Gloria Graham, Chairman of the Committee on Ethics and Religion, presented an out- '' 

standing Ethics Retreat, at Quail Roost, June 12-14. Attended by physicians, 

ministers, and sociologists, discussion was lively and pertinent. Dr. Thomas j; 

Ballentine (Neurosurgeon, Boston) was our "keynote" speaker. Many of us know and 

love Tom Ballentine who has been a part of the AMA leadership for many years. 

Tom was so impressed by our Ethics Retreat that he has vowed to duplicate it in | 

Massachusetts. A tip of the hat and heartfelt gratitude to Chairman Graham and : 

Alan Skipper (Executive Assistant, North Carolina Medical Society). Until next time' 



My best_to you and your family. 




Joseplvife E. Newell, M.D. 
President 



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Mfd. by Eli Lilly Industries, Inc. 
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"THE PHYSICIAN IS A 

DECISION MAKER, AND ALMOST 

EVERY DECISION HE MAKES 

COSTS OR SAVES MONEY." 

—Di'. William Felts, Past President, 
American Society of Internal Medicine 

More and more physicians today are beginning to 
realize tlie extent of the economic influence 
they have, and are finding ways of holding 
costs down. 

A number of studies show that the more 
physicians know about costs, the more they try 
to reduce them? And this reduction can be done 
without reducing the quality of care to the patient. 

How are they doing this? As a start they 
have become thoroughly familiar with the costs 
they incur on behalf of their patients. They know 
how much an X-ray costs, how much their 

hospital charges for routine lab tests. They're requesting copies of patients' 

hospital bills. And asking their hospitals to print the charges for diagnostic 

tests right on the order sheet. 

What else are physicians doing? Minimizing their patients' hospital 

stays, whenever possible. Reevaluating routine admissions procedures. 

Questioning the real need of the diagnostic tests they order for their 

patients. Avoiding duplicate testing. Trying to discourage their patients' 

demands for unnecessary medication, treatment or hospitalization. 

Compiling daily logs of their medical decisions and what they cost. And more. 
More physicians today realize what a tough problem we're all faced 

with. They know this is a challenge for medicine. And that physicians are 

in the best position to deal with and solve the problem. 

•PATIENT CARE Magazine- OiiHook 1977 ■Face-Off: Cost Coiitammeiit vs. Chaos:' Jamiaty 1. 1977 

Lyle CB. el ai. -Praclwe habils m a group of eight mlermsts: ANNALS OF INTERNAL MEDICINE 84 (May 1976). 594 60L 

Schroeder SA, et al. "Use of laboratory tests and pharmaceuticals: variation anumg physicians and effect of cost audit on subsequent use'.' JOURNAL OF THE 

AMERICAN MEDICAL .ASSOCIATION 225 (A ug- 20. 1973). 969 73. 





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oefore prescribing, see complete product information, 
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Do not use HEMTREX/HC Topical Medicated Foam or 
HEMTREX/HC Rectal Suppositories in patients with tuberculo- 
sis of the skin or with a history of sensitivity to any of the com- 
ponents in the preparation. Prolonged use during pregnancy 
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or nerve pills 

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of time 

Adverse Reactions: 

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BRISTOL-MYERS PROFESSIONAL PRODUCTS 
Div Bfisiol-Myers Company, Distr,. 
New York, NY 101 54 



ic 1981 Bristol-Myers Company 



backgrounder 



information sheet 



A series prepared by the North Carolina 
Medical Society staff for your benefit. 
Your comments and suggestions solicited. 
— William N. Hilliard, Exec. Director. 



NC PSROs 

Temporarily Escape Budget Ax 



Health Care Financing Administration (HCFA) staff has 
released the list of psros which have been recommended for 
termination from the program due to the severely reduced budget 
WHICH Congress is considering, With the rescission of $28 
million from the $174 million current program funding level, 
hcfa has determined that approximately 46 psros nationwide will 
not have their grants renewed and will be given 90 days to 
close down. 

None of North Carolina's eight PSROs appear on the list 
of 46 slated for termination within the 90 day close down period, 
This means that utilization review by North Carolina PSROs can 
be expected to continue, at least temporarily, under current 
funding authority unless new hcfa decisions have to be made as 
a result of congressional action, 

In April, the Office of PSRO, realizing that the program 
would have to operate under significantly reduced budget, 

ISSUED ITS "performance EVALUATION CRITERIA," USED TO RANK 

ALL 187 PSROs nationwide, Evaluations were completed by HCFA's 
Regional Offices during April and May, The evaluations were 
intended to measure the impact psros had on local medical care 
utilization, 



All PSROs, including those slated for termination and 
those that will continue to function, have just received the 
complete rankings, showing their relative position nationwide. 

North Carolina's highest ranking PSRO was sixth and the 

LOWEST one-hundred-sixth, with THE OTHER SIX SPREAD ACROSS THE 
rankings between THOSE TWO EXTREMES. 

The individual North Carolina national rankings, according 
TO A Department of Health & Human Services Memorandum just 
received, by psro, were as follows: 

6 - Western North Carolina Medical Peer Review Foundation 

10 - Piedmont Medical Foundation 

14 - Capital Area PSRO 

18 - Metroliner Medical Peer Revew Foundation 

22 - Mediqual 

71 - North Central Medical Peer Review Foundation 

84 - Central Piedmont PSRO 

106 - Northeastern North Carolina PSRO 

The Memorandum from Edward L, Kelly, Acting Director, 
Health Standards and Quality Bureau stated "The re-evaluation 

HAD two objectives, ThE FIRST WAS TO IDENTIFY PSROs THAT DID 
NOT MEET MINIMUM PROGRAM PERFORMANCE REQUIREMENTS, ThE SECOND 
WAS TO DEVELOP A RANKING OF PSROs BASED ON PERFORMANCE TO BE 
UTILIZED IN THE EVENT THAT REDUCTIONS IN PROGRAM SUPPORT WERE 
REQUIRED BY A CONGRESSIONAL BUDGET RESCISSION, We ARE NOT USING 
THE NATIONAL RANKING FOR PROGRAM REDUCTION PURPOSES AT THIS 
TIME BECAUSE WE BELIEVE WE CAN IMPLEMENT THE BUDGET RESCISSION 
WITHOUT DISCONTINUING FUNDING FOR ANY SATISFACTORILY PERFORMING 

PSROs." 

psros which are among the 46 scheduled to be phased out 
and which are now designated as "conditional" will be given an 
"informal hearing", PSROs on the list of 46 which are 

CONSIDERED "FULLY DESIGNATED" WILL BE AFFORDED A FORMAL APPEAL 

WITH THE DHHS Grant Appeals Board, as prescribed by federal 

REGULATIONS, ThESE HEARINGS WILL BEGIN IN MID-JULY. 

In SUMMARY, IT APPEARS THAT THE NORTH CAROLINA PSROs 
HAVE AT LEAST GAINED A TEMPORARY REPRIEVE FROM THE FEDERAL 

Budget ax which has fallen on 46 PSRO units. 



I 



f 



The Protective Properties of Dietary Fiber 



Denis P. Burkitt, M.D. 



INTRODUCTION 

A NUMBER of diseases charac- 
teristic of Western culture dis- 
play similar geographical and 
socio-economic patterns of distri- 
bution. One factor immensely re- 
lated to the frequency of each of 
these diseases is the fiber content of 
the diet. 

Hypotheses have been postulated 
to endeavor to explain why dietary 
fiber may afford protection against 
each of these diseases. 

FACTORS CAUSATIVE OF 

AND PROTECTIVE AGAINST 

DISEASE 

Nearly all disease results from 
contact with harmful factors in the 
environment. This applies to 
trauma, infection, neoplasia and, as 
will be emphasized below, to the 
so-called degenerative diseases. 

Not only is the body endowed 
with built-in protective mechanisms 
against disease, but deliberate eva- 
sive action can be taken against 
harmful environmental hazards 
once these are known. 
I The relationship between causa- 
I tive and protective factors can be 
likened to a water tank, with in-flow 
and out-flow pipes. The flow from 
the former raises and that from the 
latter lowers the water level. If the 
in-flow pipe represents causative 
factors and the out-flow protective 
factors, the level of the water corre- 
sponds to disease risk. Increasing 



The Old House 

Bussage. Stroud. Glouster 

GL6 SAX United Kingdom 

Presented as the second Julian Moore Memorial Lecture 

before the Buncombe County Medical Society. April 10. 

1980. 



July 1981. NCMJ 



protection, the out-flow, is tan- 
tamount to reducing cause, the in- 
flow, and vice versa. 

The potential dangers of food 
additives causing disease have been 
over-emphasized in regulations by 
the Food and Drug Administration 
to the virtual exclusion of the possi- 
bility that the removal of potentially 
protective factors might be fraught 
with greater danger. The theme of 
this paper will be to present evi- 
dence that dietary fiber which is re- 
moved with impunity from modem 
diets is strongly protective against 
many of the diseases which are 
characteristic of Western culture. 
Fiber has been deliberately re- 
moved from much of our food in the 
mistaken concept that because it 
supplies little nutrition it is con- 
sequently of no value. All too often 
in medicine that which is not under- 
stood has been considered dispens- 
able. The tonsils, appendix and 
spleen are good surgical examples. 

THE HAZARDS OF CONTACT 

WITH AN UNFAMILIAR 

ENVIRONMENT 

All living organisms become in 
time adapted to the circumstances 
in which they live. The introduction 
of a new environment against which 
they have no protection has inevi- 
table ill effects. 

The intrusion of white visitors 
into Pacific islands in the second 
half of the 19th century resulted in 
devastating epidemics of infectious 
diseases such as tuberculosis, in- 
fluenza and measles.' In time, how- 
ever, the population developed some 
immunity to these new infections. 



Approximately a century later 
another group of newly introduced 
diseases is beginning to take its toll 
in death and disability. These are 
the so-called degenerative diseases, 
an inappropriate name since they 
are not, as was once supposed, an 
inevitable consequence of advanc- 
ing age, but are characteristic of 
more economically developed 
societies. These diseases include 
such major health hazards in West- 
ern communities as appendicitis, 
diabetes, coronary heart disease 
(CHD), gallstones, diverticular di- 
sease of the colon, large bowel can- 
cer, hiatus hernia, and to a large 
extent, even varicose veins and 
hemorrhoids.-'^ 

Not only are these diseases rare 
or uncommon in rural communities 
in Africa and most of Asia, but all 
available evidence points to some 
of them being decidedly rare and 
others relatively uncommon even in 
Western countries before the sec- 
ond quarter of the present century.^ 
Their current comparable preva- 
lence between black and white 
Americans^ and between second 
and subsequent generation Japa- 
nese immigrants and Americans of 
other ethnic groups, in Hawaii and 
Califomia=^ and recently confirmed 
by personal discussions with physi- 
cians in Hawaii indicates that they 
are primarily caused by environ- 
mental rather than by genetic influ- 
ences. These and other observa- 
tions suggest that characteristically 
western diseases are the result, at 
least in part, of an environment 
against which protection has not 
been acquired. 

467 



IDENTIFYING CAUSES BY 
INVESTIGATING RESULTS 

Epidemiological associations 
Investigation of the distribution of a 
disease has often proved a powerful 
tool in unraveling its etiology. When 
the distribution of a disease can be 
delineated, some environmental 
factor having a similar distribution 
can be postulated as causative. It is 
important, however, to emphasize 
that epidemiological associations 
do not prove cause-and-effect rela- 
tionships, but they do enable the 
erection of hypotheses that can be 
tested, experimentally or other- 
wise, and verified, discarded or 
modified accordingly. 

If, on the other hand, a factor 
postulated to be the main cause of a 
disease has a distribution at var- 
iance with that of the disease in 
question the hypothesis can be 
abandoned as no longer tenable and 
unworthy of experimental testing. 
The role of epidemiology is thus to 
enable the formulation of hypoth- 
eses and to reduce by elimination 
those deserving further study. 

Associated results suggest a 
shared cause. All the results of a 
common cause tend to be not only 
common, but also associated with 
one another wherever the cause 
actively operates. Conversely they 
will all be rare or non-existent 
where the cause is minimal or ab- 
sent. Consequently, the recognition 
of associations between results sug- 
gests a shared cause. This applies to 
diseases which must be considered 
the results of causes. The closely 
similar geographical and socio- 
economic distributions of the dis- 
eases enumerated above suggest 
shared causes. In addition, the ob- 
servation that several of these dis- 
eases tend to occur together in the 
same individuals reinforces this 
conclusion.'^ This applies to factors 
both causative of and protective 
against disease. 

The significance of the order of 
disease emergence. Different dis- 
eases may require different inten- 
sities or duration of exposure to a 
shared environmental factor before 
they become manifest. In a commu- 
nity exposed from birth the required 
duration of exposure for each dis- 
ease would be reflected in the age at 



which the disease most commonly 
appears. On the other hand, when 
the responsible environment is 
newly introduced into a commu- 
nity, the time that must elapse be- 
fore the appearance or increased 
prevalence of a disease will depend 
on the period that must pass after 
contact with the new environmental 
factor. This will differ with each 
disease as does the age of onset in 
Western countries. It is significant 
that the order of emergence of many 
characteristically Western diseases 
in Third World countries is closely 
similar to that of their emergence 
with age in Western communities.' 
Appendicitis, hemorrhoids and 
diabetes are diseases encountered 
at a relatively young age in the 
West, and in less affluent commu- 
nities they increase in prevalence 
before varicose veins, gallstones 
and coronary heart disease, which 
appear considerably later. Hiatus 
hernia and diverticular disease ap- 
pear to be the last of all to become 
common diseases. There are nota- 
ble exceptions to this general rule 
epidemiologically. As will be indi- 
cated below the protective mecha- 
nisms of fiber operate in different 
ways. It is possible to have enough 
fiber to protect against bowel disor- 
ders, while at the same time eating 
enough fiber-depleted carbohydrate 
foods to induce certain metabolic 
effects of such diets. 

The island of Nauru in the Pacific 
is a good example of the effect of 
changed environment where the 
change to Western diet has been 
dramatic on disease patterns. The 
prevalence of diabetes and obesity 
has soared, « appendicitis has 
emerged but CHD, gallstones and 
diverticular disease have not yet 
emerged.* Among the Pima In- 
dians," however, both diabetes and 
gallstones have become extremely 
common, but this population still 
suffer much less from CHD than do 
other Americans and diverticular 
disease and hiatus hernia remain 
uncommon. Diabetes and obesity 
are rampant among black South Af- 
ricans, but gallstones and CHD re- 
main uncommon and diverticular 
disease rare. 



Zimmet, Personal Communication. 1978. 



468 



MAJOR DIETARY CHANGES 

PRECEDING DISEASE 

INCREASE 

The environmental factors that 
characterize Western culture are 
diverse and numerous. In view of 
the fact that the diseases listed 
above are directly or indirectly re- 
lated to the content and behavior of 
the alimentary tract it would seem 
logical to consider dietary changes 
before attempting to incriminate 
other environmental factors. The 
major changes that have taken place 
in the proportions of various food 
components consumed both in 
Western countries in the past, and 
in developing countries more re- 
cently, have been: ( 1 ) a reduction in 
total carbohydrate intake asso- 
ciated with a replacement of non- 
refined by refined carbohydrates, 
sugar in many countries now pro- 
viding 50% of the total: (2) a con- 
sequent reduction in fiber, and (3) a 
reciprocal increase in the propor- 
tion of energy derived from fat. 

The increase in fat has been pos- 
tulated as one cause of CHD, 
gallstones, obesity and colo-rectal 
cancer. Increased sugar has been 
incriminated in the pathogenesis of 
diabetes and obesity, but all of these 
diseases have been shown to be re- 
lated to a deficiency of fiber and of 
cereal fiber in particular in the diet. 
Hypotheses that have been pos- 
tulated to explain the pathogenesis 
of some of the group of illnesses 
now generally referred to as "West- 
em Diseases" will be outlined below. 
In each of these, fiber-depleted diets 
have been incriminated as a causa- 
tive factor, but it seems preferable 
to view fiber as protective against, 
rather than its absence causafive of 
disease. 

THE MECHANICAL EFFECTS 
OF CONSTIPATION 

Constipation. The most common 
and most important single cause of 
constipation is a deficiency of fiber, 
and that of starchy staple foods in 
particular, in the diet. Fiber is 
strongly protective against consti- 
pation. It ensures that large-bowel 
content is bulky in volume and soft 
m consistency. This is partly due to 
its water holding capacity, but also 
to other mechanisms not yet fully 

Vol. 42, No. 7 



understood. The pentose fraction of 
fiber exerts the greatest effect, and 
this is much more prominent in 
cereals than in fruits and leafy veg- 
etables. Legumes (peas and beans) 
and tubers (root vegetables) are 
more effective than leaf vegetables 
and fruit, but less so than cereals.'" 

Whereas people in communities 
subsisting mainly on carbohydrate 
foods retaining their fiber pass in the 
region of 3(X)-600gof stool daily, the 
amount voided in Western commu- 
nities averages only 80-120g" with 
the exception of vegetarians who 
may pass double this amount. 
Western communities can be con- 
sidered almost universally consti- 
pated by world standards. 

Raised intra-abdominal pres- 
sures. When sitting in a raised 
Western type toilet seat the strain- 
ing necessitated to evacuate firm 
small-volume fecal masses from the 
rectum can raise intra-abdominal 
pressures to nearly 200 cm: H2O, 
whereas concurrent intra-thoracic 
pressures rise only to about 70 cm. 
These pressures are significantly 
less when defecating in the tradi- 
tional squatting position.'- 

These raised intra-abdominal 
pressures have been postulated to 
contribute to the following diseases: 

Hiatus Hernia 

The only hypothesis for the cau- 
sation of this upward protrusion of 
the gastro-esophageal junction 
through the esophageal hiatus in the 
diaphragm that is consistent with 
the epidemiological features of the 
disease is the one set out below. 

If a ball with a hole in its wall is 
squeezed the contents will be read- 
ily extruded through the hole. The 
abdominal cavity, surrounded by 
muscles, can be likened to such a 
ball. The aperture in the diaphragm 
transmitting the esophagus is the 
hole in its wall. It is not difficuh to 
visualize how straining the muscles 
of the abdominal wall could force 
the upper end of the stomach 
through the esophageal hiatus and 
into the thoracic cavity. 

Consistent with this hypothesis is 
the routine practice of radiologists 
who deliberately raise intra-abdom- 
inal pressures in order to demon- 



strate the presence of a hiatus her- 
nia. 

Since fiber is protective against 
constipation it must protect against 
hiatus hernia if this hypothesis is 
accepted. This defect is not known 
to be other than rare in any commu- 
nity in which stools are customarily 
large and soft. 

Varicose Veins 

All raised intra-abdominal pres- 
sures are readily transmitted to the 
major venous trunks draining the 
leg veins. This causes a retrograde 
flow of blood under increased 
pressure into these veins. This has 
been postulated to result over a 
period of time in dilation of the prox- 
imal segments of the veins. The 
stretching of the walls to which the 
valve cusps are attached renders 
them incompetent. This valve fail- 
ure progresses sequentially from 
valve to valve from above down- 
wards. The intra-venous pressures 
raised both by the column of unsup- 
ported blood and the pressures gen- 
erated by abdominal straining have 
been postulated to be a major factor 
in the causation of varicose veins. '^ 
Although it is not suggested that this 
is a sole cause, adequate dietary 
fiber, by minimizing the necessity to 
strain at stool, can be considered 
protective. 

Raised intra-liiminal pressures 

Diverticular Disease 

The presence of small volume 
firm fecal masses within the colon 
necessitates exaggerated contrac- 
tions of the muscle in the bowel wall 
in order to propel its resistant con- 
tent onwards. This raises the 
pressures within the lumen of the 
bowel and these are believed to be 
the fundamental cause of diver- 
ticula, which are protrusions of the 
lining mucosa of the colon forced 
out through weak spots in the 
over-lying muscle coat.'^ Again 
fiber, by ensuring that the bowel 
content is voluminous and soft, pre- 
cludes the necessity for exaggerated 
activity on the part of the bowel 
musculature and can consequently 
be considered protective against di- 
verticulosis. The routine prescrip- 
tion of fiber-rich diets has reduced 
the requirement of surgical inter- 



vention in diverticular disease by up 
to 90% and symptoms can be re- 
lieved in over 80% of patients."' 

Appendicitis 

It is now generally accepted that 
appendicitis is initially an obstruc- 
tive phenomenon with an inflam- 
matory process subsequently 
superimposed. It would be difficult 
to explain the sequence of clinical 
symptoms and the usual limitation 
of pathological changes to the distal 
portion of the appendix on other 
grounds. 

The presence of firm fecal parti- 
cles in the appendix seem the most 
likely cause of lumen obstruction, 
occasionally by impaction, but 
more often by contraction of circu- 
lar muscles as occurs in the pelvic 
colon to occlude its much wider 
lumen to contribute in the develop- 
ment of diverticular disease. 

Other effects of constipation 
Hemorrhoids 

The work of Thomson"' suggests 
that these can no longer be consid- 
ered as varicosities of hemorrhoidal 
veins, but rather as a prolapse of 
vascular sub-mucosal cushions 
which normally surround the upper 
anal canal to ensure fecal conti- 
nence. 

Not only does abdominal strain- 
ing result in venous engorgement of 
these cushions, but in addition the 
shearing stress of forcing firm fecal 
masses along the anal canal rup- 
tures their attachments to the 
sphincter muscles with their resul- 
tant prolapse towards the anal 
orifice. 

Constipation thus appears to be a 
major causative factor and this ob- 
servation is being increasingly acted 
upon in surgical clinics in Britain 
and The Netherlands. In many of 
these clinics the initial treatment for 
all patients with hemorrhoids is to 
prescribe a diet rich in cereal fiber, 
and this has been shown, as in the 
case of diverticular disease, to 
drastically diminish the number re- 
quiring surgical intervention.'^ 

Colon Cancer 

The most favored current 
hypotheses for the causation of 
colon cancer incriminates bacterial 



July 1981. NCMJ 



469 



metabolites of bile acids, '^ N-nitroso 
compounds"* or derivatives of 
cholesterol.-" 

No matter what the causes of 
colon cancer, there is increasing 
consensus of belief that fiber, and 
cereal fiber in particular, is protec- 
tive against this disease. 

Epidemiological evidence indi- 
cates that almost all communities 
with high rates of large bowel 
cancer consume diets with a high fat 
and a low fiber content and vice 
versa. Recent comparisons be- 
tween rural Finns and populations 
in both Copenhagen and New York 
have strengthened belief that fiber, 
and cereal fiber in particular, may 
confer protecUon. Rural Finns have 
only one quarter the color cancer 
rates observed in Copenhagen or in 
New York.^' Fat consumption is 
closely comparable in all three 
communities but the Finns consume 
nearly twice as much fiber and par- 
ticularly cereal fiber, as do the other 
two, and as a consequence void a 
much greater volume of stool. 

Several mechanisms, which 
probably operate in combination, 
have been postulated to account for 
the protective action of fiber against 
colon cancer. 

By diluting bile acids in an in- 
creased fecal volume and by other 
means not yet understood it reduces 
the bacteria! degradation of primary 
to the secondary bile acids which 
have been postulated to be car- 
cinogenic.^- Fiber can lower fecal 
pH and colon cancer risk in differ- 
ent communities has been shown to 
relate directly to fecal pH values. 
The various mechanisms whereby 
lowering fecal pH may protect 
against colon cancer have been 
summarized by Burkitt.-'' 

Fiber has been shown to bind 
various poisons and toxins in the 
gut, and may well act likewise on 
fecal carcinogens.-^ 

Whatever the causes of colon 
cancer, they will be less harmful if 
diluted in a large fecal volume than 
if concentrated in a small one. In 
addition it would seem prudent to 
ensure their more rapid transit 
through the gut, and more frequent 
elimination, with consequent re- 
duction in their period of contact 
with mucosa, than to allow them to 



lie stagnant in the bowel for days or 
weeks. 

Fiber as protection against other 
effects of fiber-depleted diets 

Excessive Energy Intake 

Fiber, by increasing the bulk rel- 
ative to the energy content of food, 
puts a brake on excessive nutrition. 
The earlier sense of satiety achieved 
when eating fiber-rich foods miti- 
gates against the excessive energy 
intake occasioned by consumption 
of foods composed solely of en- 
ergy.-'^ Thus fiber can be considered 
protective against obesity. This in 
no way negates the recent important 
work in incriminating the energy 
burning property of brown fat cells 
as another important protection 
against excessive fat storage.'" 

Excessive Rate of Nutrient 
Absorption 

Fiber-depleted diets tend to result 
in abnormal fluid content in the 
small bowel. This allows over-rapid 
absorption of energy into the circu- 
lation, most of the nutrients, and 
sugars in particular, being absorbed 
from the upper jejunum. Certain 
components of fiber on the other 
hand, and guar gums in particular, 
render the intestinal content more 
viscid, so that the energy escapes 
more slowly throughout almost the 
entire length of the jejunum and 
much of the ileum. Over rapid ab- 
sorption of energy imposes exces- 
sive demands for rapid production 
of insulin, whereas the demands 
made where the absorption rate is 
reduced are gradual and exerted 
over a prolonged period. 

The excessively rapid release of 
energy from the gut is believed to be 
important in the pathogenesis of 
diabetes,-'' and certain elements of 
fiber can thus be considered pro- 
tective against this disease. 

This hypothesis is enhanced by 
the excellent therapeutic results 
achieved by treating diabetics with 
high carbohydrate diets, rich in 
fiber, but low in sugar,'-'* an obser- 
vation in keeping with the epidemi- 
ological features of the disease, but 
at variance with what has been 
customary treatment. Guar-gums 
obtainable principally from the In- 
dian cluster bean have proved 



especially effective in controlling 
blood sugar anomalies. 

Lithogenicity of Bile 

Cholesterol gallstones are the re- 
sult of production by the liver of 
cholesterol saturated bile. Crystals 
form and provide the basis for stone 
formation when the cholesterol 
content of the bile is in excess of the 
amount of bile acids and lecithin 
available to keep it in solution. 
Fiber both reduces the cholesterol 
content and increases the relative 
proportion of beneficial chenode- 
oxycholate over the less valuable 
deoxycholate in the bile.-" 

For these and other reasons fiber 
is believed to afford protection 
against cholesterol gallstones. 

There are of course many other 
factors contributing to their cause 
and their predominance in women 
suggests the implication of hor- 
mones. 

It is of interest that the Japanese 
were almost exempt from choles- 
terol gallstones until they adopted a 
more Western style of diet after the 
second world war.^" 

PRACTICAL PROTECTIVE 
MEASURES 

The mechanisms postulated 
whereby fiber may confer protec- 
tion against some Western diseases 
are consistent with epidemiological 
evidence and make biological 
sense. They cannot yet be consid- 
ered as proven, but it is neither sci- 
entifically nor morally justifiable to 
postpone the implementation of 
reasonable hypotheses until abso- 
lute proof has been acquired. There 
are numerous examples in medical 
history to condemn such an at- 
titude. In accordance with Lind's 
observations that fresh fruit and 
vegetables afforded protection 
against scurvy, Capt. Cook acted on 
his recommendations a century 
before vitamin C was isolated and 
lost not a man from scurvy when 
discovering New Zealand. 

There is no good evidence that 
returning to our diet some of the 
fiber that has been removed will 
have ill effects, other than in rare 
unusual situations, whereas the 
potential benefits to be gained are 
enormous. Any postulated ills of 



470 



Vol. 42, No. 7 



( 



such action must be assumed to 
have been present until a century 
ago. If so where is the evidence? 

Relatively simple dietary changes 
could have highly beneficial effects 
and these would include: 

1. A greatly increased consump- 
tion of bread, but substituting whole 
meal, or near whole meal, for white 
flour. 

2. Liberal consumption of fiber- 
rich breakfast cereals, either oat- 
meal porridge or packaged break- 
fast foods, preferably with the addi- 
tion of one heaped tablespoonful of 
miller's brand per person daily. 

3. Reduction of sugar intake by 
about a half. 

4. Liberal consumption of pota- 
toes, preferably retaining their 
skins, and neither cooked in, nor 
eaten with, fat. 

5. A reduction in consumption of 
fat to compensate for increased 
energy intake from carbohydrates. 
This entails cutting down meat con- 
sumption since nearly 40% of even 
lean meat as currently produced in 
Western countries is composed of 
fat. Moreover, meat is the most un- 
economical manner in which to ob- 
tain nutrition. 

6. A radical reduction in confec- 
tionery composed of white flour. 



sugar and fat. Total prohibition is 
not practicable since to encourage 
compliance idealism must be wed- 
ded to acceptability. 

Such protective measures would 
correspond to erecting a fence 
round the edge of a cliff to prevent 
men falling over, whereas thera- 
peutic medicine, which is pre-emi- 
nently directed to salvaging casual- 
ties, can be likened to the stationing 
of ambulances at the foot of the cliff. 

The money spent on the latter and 
less effective approach is over 100 
times that devoted to the former. Do 
we not deserve the ironical com- 
ment of the American poet Ogden 
Nash who wrote — "We are making 
great progress, but we are headed in 
the wrong direction."? 



References 

1 . Zimmet P: Pacific islands of Naui-U . Gui-ala and West- 
em Samoa. Trowel! HC, Burltitt DP. eds. Western dis- 
eases: tfieir emergence and prevention. London. Ed- 
ward Arnold. (In Press). 

2. Cleave TL: The saccharine disease: the master disease 
of our time. New Canaan, Keats Publishing Inc.. 1975. 

3. Burkitt DP: Some diseases characteristic of modern 
western civilization. Br Med J 1:274-278, 1973. 

4. Burkitt DP, Trowell HC, eds. Refined carbohydrate 
foods and disease: some implications of dietary fibre. 
London. New York, Academic Press, 197.^. 

5. Stemmermann GN: Pattemsof disease among Japanese 
living in Hawaii. Arch Environ Health 20:266-273, 1970. 

6. Burkitt DP: Relationship as a clue to causation. Lancet 
2:1237-1240, 1970. 

7. Burkitt DP: Relationships between diseases and their 
etiological significance. Am J Clin Nutr 30:262-267, 
1977. 

8. Zimmet PZ, Whitehouse S, Jackson L, Thoma K: High 
prevalence of hyperuricaemia and gout in an urbanised 
Micronesion population. Br Med J 1:1237-1239, 1978. 

9. Reid JM, Fullmer SD, Pettigrew KD, et al: Nutrient 



intake of Pima Indian women: relationships to diabetes 
mellitus and gallbladder disease. Am J Clin Nutr 
24:1281-1289. 1971. 

Southgate DA. Bailey B, Colinson E, Walker AF: A 
guide to calculating intakes of dietary fibre. J Human 
Nutr 30:303-313, 1976. 

Burkitt DP, Walker AR, Painter NS: Dietary fiber and 
disease, JAMA 229:1068-1074, 1974. 
Fedail SS, Harvey RF, Bums-Cox CJ: Abdominal and 
thoracic pressures during defaecation. Br Med J 1:91, 
1979. 

Burkitt DP: Varicose veins: facts and fantasy. Arch 
Surg 111:1327-1332, 1976. 

Painter NS: Diverticular disease of the colon: a defi- 
ciency disease of western civilization. London, 
Heinemann Medical Books, 1975. 
Gear JS. Ware A, Fursdon P, et al: Symptomless diver- 
ticular disease and intake of dietary fibre. Lancet 
1:511-514, 1979. 

Thomson WH: The nature of haemorrhoids. Br J Surg 
62:542-552, 1975. 

Huibregste K: Non-surgical therapeutic possibilities in 
haemorrhoidal disease. In haemorrhoids: current con- 
cepts of causation and management. London, Roy Soc 
Med International Congress and Symposium Series. 
No. 12, pp 27-30, 1979. 

Hill MJ: Bacteria and the etiology of colonic cancer. 
Cancer 34:lSupp)8l5-8l8, 1974. 

Bruce WR, Varghese AJ, Want S, Dion P: The en- 
dogenous production of nitroso compounds in the colon 
and cancer at that site. Tokyo: Proceedings of the Prin- 
cess Takamtsu Conference, January, 1979. 
Crtjse P. Lewin M, Clark CG: Dietary cholesterol is 
co-carcinogenic for human colon cancer. Lancet 
1:752-755, 1979. 

Maclennan R, Jenson OM, Mosbech J, Vuon H: Diet, 
transmit time, stool weight and colon cancer in the 
two Scandanavian populations. Am J Clin Nutr 3!: 
(Supp)S239-S24l, 1978. 

Pomare EW, Heaton KW: Alteration of bile salt 
metabolism by dietary fibre (bran). Br Med J 4:262-264, 
1973. 

Burkitt DP: Fibre in the aetiology of colo-rectal cancer. 
Progress in cancer research and therapy. New York, 
Raven Press. (In Press). 

Ershoff BH: Antitoxic effects of plant fiber. Am J Clin 
Nutr 27:1395-1398, 1974. 

Heaton KW: Food fibre as an obstacle to energy intake. 
Lancet 2:1418-1421, 1973. 

Jung RT, Shetty PS, James WP, et al: Reduced ther- 
mogenesis in obesity. Nature 279:322-333. 1979. 
Jenkins DJA, Wolever TMS, Leeds AR, et al: Dietary 
fibres, fibre analogues and glucose tolerance: impor- 
tance of viscosity. Br Med J 1:1392-1394, 1978. 
KiehmTG, Anderson J W, Ward K: Beneficial effects of 
a high carbohydrate, high fiber diet on hyperglycemic 
diabetic men. Am J Clin Nutr 29:895-899. 1976. 
Heaton KW: Are gallstones preventable? World Med 
14:21-23, 1978. 

Yamamoto S: "Japan." In western diseases: their 
emergence and prevention. (Eds. Trowell HC. Burkitt 
DP). London, Edward Arnold. (In Press). 



July 1981. NCMJ 



471 



High Risk Indicators of Fetal and Neonatal Mortality 

in Durham County, N.C. 



Craig D. TurnbuU, M.P.H., Ph.D., John D. Fletcher, M.D., M.P.H., and 

Anne B. Klein, A.B. 



ABSTRACT Scurletis, TurnbuU, 
and Corkey ' emphasized the need for 
each community to subclassify its 
population regarding the impact of 
selected characteristics as indicators 
of high risk of fetal and infant mor- 
tality. The findings of this study are 
additional evidence for this need 
since many of the high risk indicators 
suggested by Scurletis et al.' for 
North Carolina in 1970 were also op- 
erant in Durham County, North 
Carolina. 

INTRODUCTION 

DUE to the lack of significant re- 
duction of fetal and neonatal 
mortality rates researchers have 
continued to study these morbid 
events. To date, little has been ac- 
complished in terms of practical 
utilization of available information 
regarding these events. This com- 
munication speaks to this point. 

Efforts have been directed at en- 
tire populations and have not con- 
centrated on those subpopulations 
(or groups) at greatest risk. As a 
result, those at greatest risk may 
not have been effectively served. 
When one attempts to identify 
such subpopulations, mechanisms 
should be developed which can be 
applied simply, which utilize avail- 
able information and which are 
easily interpreted. This could be 
accomplished by identifying sub- 
populations which experience high 



From the Department of Biostatistics. University of North 

Carolina at Chapel Hill (Dr. Tumbull and Ms. Klein) and the 

Department of Health, Durham County. N.C. (Dr. 

Fletcher). 

Reprint requests to Dr. TurnbuU. 



fetal and neonatal mortality rates. 

This communication is based on 
the prior work of Scurletis, et al.' 
who demonstrated important re- 
lationships between fetal, neonatal 
and postneonatal mortality and the 
following indicators of high risk for 
both whites and nonwhites: 

Age of parturient (AGE < 18 and 
AGE > 34) 

Birth order (BO > 4) 

History of a previous live birth 
which is now dead (PLBND) 

History of a previous fetal death 
(PFD) 

Level of educational attainment 
(EDUC < 9 and 9-11) 

Out of wedlock pregnancy (OW) 

Donnelly, et al.-, as well as Sha- 
piro and Abramowicz^ and Turn- 
bull^ reported that offspring of par- 
turients under 20 and those over 29 
years of age were at risk of perinatal 
death (fetal or neonatal). Donnelly, 
et al."* noted an increase in parity 
was associated with an increase in 
the risk of perinatal mortality, even 
after adjusting for race, age and se- 
lected other factors. 

High rates of infant mortality 
have been noted by Stickle and Ma^ 
for parturients who experienced a 
previous fetal death. In addition, 
level of education has been found 
to be useful in identifying high risk 
parturients; a low level of educa- 
tional attainment has been noted to 
be an indicator of high fetal and in- 
fant mortality. '•^•*'*"' Also. Fletcher 
and TurnbuU" noted that illegiti- 
macy (or out of wedlock pregnancy) 
is also a high risk indicator of fetal 
and infant mortality. 

The purposes of this study are: 



(1) to describe the trends in Dur- 
ham County's fetal and neo- 
natal mortality rates from 
1966 to 1976 and to observe if 
the rates differed for whites 
and nonwhites, 

(2) to compare Durham County's 
fetal and neonatal mortality 
rates with those reported by 
Scurletis, et al.' for North 
Carolina in 1970, and 

(3) to examine Durham County's 
high risk characteristics since 
interest centered on deter- 
mining if the high risk catego- 
ries defined by Scurletis, et 
al. ' for North Carolina in 1970 
were also operant in Durham 
County (the two-year period 
of 1975-76 was employed in 
this effort due to the relatively 
small number of events for 
any specific, single year in 
Durham County). 

METHODS 

Vital records for Durham County 
for 1966 and 1976 were examined to 
study pregnancies which resulted in 
either a live birth, fetal death or 
neonatal death. The risk character- 
istics mentioned above were se- 
lected for study since they have 
been shown to be important indi- 
cators of fetal and infant mortality. 
The data were analyzed separately 
for whites and nonwhites in order 
to discern if similar high risk char- 
acteristics exist for these racial 
groups. 

This communication presents de- 
scriptive analyses; that is, mortality 
rates for various subpopulations are 
compared to relevant total popula- 



472 



Vol. 42, No. 7 



ions. If the rate for a subpopulation 
s larger than the relevant total pop- 
ilation rate, the authors consider 
his to be an important clinical 
Inding which indicates the subpop- 
ilation is at high risk. 

RESULTS 

Durham County's fetal death 
rates (per 1,000 deliveries) by race 
for 1966 through 1976 are shown in 
Figure 1. The trends are erratic; 
however, they show that whites 
experienced lower rates than non- 
whites. This finding is in agreement 
with that reported by Scurletis, et 
al.' for North Carolina in 1970. 
Trends of neonatal death rates (per 
jjl.OOO live births) by race for Dur- 
I ham County from 1966 through 1976 
are also erratic (Figure 2). The rates 
for nonwhites exceeded those for 
whites for all years except 1968 and 
1973. 

While it is neither the purpose, 
nor within the scope of this paper 
to attempt to explain variations in 
fetal and neonatal rates over time, it 
can be useful to compare briefly the 
Durham County data to those re- 
ported by Scurletis, et al.^ for North 
Carolina in 1970. The authors will 
then examine more closely the Dur- 
ham County data for 1975-76 to note 
if the risk characteristics reported 
by Scurletis, et al.' were also oper- 
ant in Durham County. 

The prior study' reported a white 
fetal mortality rate of 13.5 per 1 ,000 
deliveries for North Carolina in 
1970 and a nonwhite fetal mortality 
rate of 22.9 per 1,000 deliveries. 
Similar data for Durham County's 
white and nonwhite populations 
were 12.5 and 19.3, respectively, re- 
flecting a more favorable fetal mor- 
tality experience in Durham Coun- 
ty. A comparison between Durham 
County and North Carolina neo- 
natal death rates revealed that in 
1970, Durham County whites ex- 
perienced a neonatal death rate of 
12.6 per 1,000 live births as com- 
pared to 15.1 for North Carolina. 

Such a favorable comparison did 
not hold for Durham County's non- 
white population versus that for the 
state since the neonatal death rates 
were 31.0 and 24.0, respectively. 

Table I presents a portion of the 
findings for fetal and neonatal mor- 

JuLY 1981, NCMJ 



Figure 1. Fetal Death Rates by Race 
Durham County, 1966-1975 




1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 
Year 



tality reported by Scurletis, et al.' 
for North Carolina in 1970. Seven of 
the eight white subpopulations were 
at high risk of fetal death since their 
rates were higher than the total 
white fetal death rate — the excep- 
tion was for parturients under 18 
years of age (AGE < 18). The fol- 
lowing nonwhite subpopulations 
were at high risk of fetal death: AGE 
> 34, BO > 4, EDUC < 9, OW, 
FED and PLBND. Each of the nine 
nonwhite fetal death rates (i.e., 
eight subpopulations and the total 
rate) was higher than its white 
counterpart. 

Each of the eight white subpopu- 
lations were at high risk of neonatal 
death since each rate was larger 
than the total white neonatal rate. In 
addition, seven of the eight non- 
white subpopulations were at high 
risk of neonatal death since each 



rate was larger than the total non- 
white neonatal rate — the exception 
was for nonwhite parturients in the 
EDUC 9-11 subpopulation. Each of 
the nine nonwhite neonatal death 
rates was larger than its white 
counterpart. 

Table II presents fetal and neo- 
natal death rates for whites and 
nonwhites in Durham County for 
1975 and 1976. Due to the relatively 
small size of the populations at risk, 
the indicators employed by Scur- 
letis, et al.' were redefined as fol- 
lows: 

AGE < 18 and AGE > 34 — no 
change 

Education (EDUC < 12) 
OW — no change 
Parity (PAR > 3) 
PFD — no change 
PLBND — no change 



Figure 2. Neonatal Death Rates by Race 
Durham County, 1966-1976 




1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 
Year 



473 





Table 1: 


Fetal 


and Neonatal Death Rates by Race, 


North Carolina, 


1970 




Characteristic 


Fetal death 


rate- 


Neonatal death rate" 




White 


Nonwhtte 


WhHe 


NonwhKe 


AGE < 18 
AGE > 34 
B0>4 
EDUC < 9 
EDUC 9-11 




124 
27.5 
23.5 
19.5 
13.9 


21.4 
53.3 
38.3 
28.4 
22.6 


28.0 
15.3 
18.1 
19.3 
16.8 


30.6 
27.9 
28.0 
29.7 
23.0 


PFD 
PLBND 






22 1 
20.3 
21.2 


26.5 
40.8 
30.4 


226 
21.0 
34.1 


27.2 
36.2 
48.5 


Total 


population 




13.5 


22.9 


15.1 


24.0 



Source: Adapted from Scurletis. T. D., Turnbull. C. D. and Corkey, D. C : High Risk Indicators of Fetal, Neonatal and 
Postneonatal Mortality, NCMJ. 34: 183-192. 1973 
•Rate per 1,000 deliveries 
"Rates per 1.000 live births 



The data for white fetal mortality 
show that the following subpopula- 
tions experienced a higher rate than 
the total white fetal death rate: AGE 
< 18, AGE > 34, EDUC < 12, OW 
and PFD. We suggest these five 
white subpopulations in Durham 
County are at high risk of fetal 
death. 

Only four of the seven nonwhite 
subpopulations were found to be at 
high risk of fetal death: AGE > 34, 
PAR > 3, PFD and PLBND. Six of 
the eight nonwhite fetal death rates 
(i.e., seven subpopulations and the 
total rate) were larger than their 
white counterparts. The exceptions 
were AGE < 18 and OW, otherwi.se 
nonwhites were at greater risk of 
fetal death than whites. 

Six of the seven white subpopu- 
lations were at high risk of neonatal 
death since their rates were larger 
than the total white neonatal rate — 
the exception was OW. The data for 
nonwhite neonatal death revealed 
that the following four subpopula- 



tions were at high risk since each 
rate was larger than the total non- 
white neonatal rate: AGE < 18, 
AGE > 34, EDUC < 12 and OW. 

Seven of the eight nonwhite neo- 
natal death rates were larger than 
their white counterparts — the ex- 
ception was for parturients who ex- 
perienced PLBND. 

The following presents a com- 
parison of the most important high 
risk indicator of fetal and neonatal 
death by race for North Carolina in 
1 970 versus that for Durham County 
in 1975-6: 





North Carolina 


Durham County 




1970 


1975-6 


Fetal death 






White 


AGE > 34 


OW 


Nonwhite 


AGE > 34 


AGE > 34 


Neonatal death 






White 


PLBND 


PLBND 


Nonwhite 


PLBND 


AGE > 34 



These data reinforce some of the 
findings of Scurletis. et al.', since 
one notes a similar highest risk 
characteristic for nonwhite fetal 



Table II: 


Fetal and Neonatal Death Rates and Populations at Risi( 
(PAR) by Race, Durham County, N.C., 1975-6 










Fetal death 






Neonatal death 






White 


NonwhHe 




White 


Nonwhite 


Characteristic 




Rale' 


# at 
risk 


Rate' 


# at 
risk 


Rate' 


# at 
risk 


Rate" 


# at 
risk 


AGE < 18 
AGE > 34 
EDUC < 12 




9.5 
17.2 
9.3 


105 

58 

428 


3.9 
42.3 
13.4 


259 

71 

746 


19.2 
17.5 
4.7 


104 

57 

424 


27.1 
44.1 
27.0 


258 

68 

704 


PAR > 3 

PFD 

PLBND 




25.6 
5.1 

10.2 
0.0 


78 
197 
392 

46 


14.9 
286 
32 7 
29.9 


803 

280 

367 

67 


0.0 

5.1 

7.7 

21.7 


76 
196 
388 

46 


21.5 
7.4 
8.4 

15.4 


791 

272 

355 

65 


Total population 




6.7 


2100 


18.2 


1755 


4.3 


2086 


16.3 


1723 



■Rate per 1.000 deliveries 
"Rate per 1.000 live births 

474 



death in both North Carolina and 
Durham County (AGE > 34) and 
also for white neonatal death in 
North Carolina and Durham County 
(PLBND). 

It is suggested that each commu- 
nity screen both its white and non- 
white population as to high risk of 
fetal and neonatal death by utilizing 
the indicators suggested by Scur- 
letis, et al.' It is recognized that it 
may be necessary to modify the 
characteristics of risk for individual 
communities in order to accommo- 
date local demographics and the ex- 
periences of prior years. We quote 
Scurletis, et al.': "By studying the 
characteristics of the birth and 
death population of a previous year, 
the characteristics of the high risk 
group can be established by asking 
women of childbearing age six criti- 
cal questions: 

1. What is your age? 

2. How many pregnancies have 
you had? 

3. How many years of education 
have you completed? 

4. Have you had (experienced) a 
previous fetal death? 

5. Have you had (experienced) a 
previous child born alive who 
is now dead? 

6. What is your marital status? 
The responses to these questions 

will classify each woman with re- 
spect of risk of fetal, neonatal and 
postneonatal death." 

References 

1 . Scurletis TD. Turnbull CD. Corkey DC: High risk indi- 
cators of fetal, neonatal and postneonatal mortality. NC 
Med J 34:18.1-192, 1973. 

2. Donnelly JF, Flowers CE.CreadickRN.etal: Prenatal, 
fetal and environmental factors in perinatal mortality. 
Am J Obslel Gynecol 74:I24.S-I2.'^4. I9.';7. 

3. Shapiro S. Abramowicz M: Pregnancy outcome corre- 
lates identified through medical record-based informa- 
tion. Am J Public Health .59: 1629-1650. 1969. 

4. Turnbull CD: Multi-stage analyses of three perinatal 
outcomes: death, birth weight, and gestational age. In- 
stitute of Statistics Mimeo Series. No. 810. University 
of North Carolina al Chapel Hill. 1-239. 1972. 

5. Donnelly JF. et al: A review of methodology in the 
North Carolina study of felal and neonatal deaths. In 
Chipmann SS. et al: Research methodology and needs 
in perinatal studies. Proceedings of the Conference on 
Research Methodology and Needs in Perinatal Studies 
(Chapel Hill, N.C). Springfield, Illinois. Charles C. 
Thomas. 1966, Chapter 1. 

6. Stickle G. Ma P: Some social and medical correlates of 
pregnancy outcome. .\m J Obstet Gynecol 127: 162-166. 
1977. 

7. Maternal and Child Health Statistics. 1972. North Car- 
olina Department of Human Resources, Division of 
Health Services, Raleigh, N.C. July, 1973. 

8. Maternal and Child Health Statistics, 1973. North Car- 
olina Department of Human Resources, Division of 
Health Services. Raleigh. N.C. May. 1975. 

9. Maternal and Child Health Statistics. 1976. North Car- 
olina Department of Human Resources, Division of 
Health Services, Raleigh, N.C. January, 1978. 

10. Levy M, Scurletis TD. Siegel E, et al: The determinants 
of postneonatal mortality in North Carolina, 1%7-1%8. 
Personal Health Monograph. Raleigh. N.C, 1-197, 
1973. 

11. Fletcher JD. Turnbull CD: Early and periodic screen- 
ing, diagnosis and treatment in Durham County. North 
Carohna. NC Med J 38:652-653, 1977. 

Vol. 42, No. 7 



Hereditary Deficiency of Thyroxine-Binding Globulin 



William D. Wilson, Jr., M.D.,* and Robert P. Schwartz, M.D.** 



ABSTRACT A case report is pre- 
sented to illustrate the need for per- 
forming a T3 resin uptake along 
with a T4 to prevent the treatment 
of euthyroid patients who have 
quantitative thyroxine-binding glob- 
ulin (TBG) abnormalities. 

THE evaluation of thyroid func- 
tion routinely includes the mea- 
surement of T3 resin uptake as an 
indirect index of available thyrox- 
ine-binding globulin (TBG) sites. A 
decreased serum thyroxine (T4) in 
conjunction with an increased T3 
resin uptake suggests decreased 
thyroxine binding capacity of TBG 
or TBG deficiency. 

We report the case of a boy with a 
low T4 who was treated for hypo- 
thyroidism before T3 resin uptake 
and TBG levels revealed TBG defi- 
ciency. 

CASE REPORT 

The patient, a 10 4/12-year-old 
white male, was initially seen by his 
private physician at age 8 because of 
obesity and was found to have a T4 
of 2.6 |U.g/dl. He was started on des- 
sicated thyroid, 2 grains daily, 
which was later increased to 4 
; grains. The thyroid medication was 
! discontinued after six months due to 
a lack of clinical response. He was 
lost to follow-up until 10 years of 
age when a repeat T4. was 1 .7 yu,g/dl 
with a normal TSH. Because of the 



•Department of Pediatrics, Charlotte Memorial Hospital 
and Medical Center. Charlotte, N.C. 

••Assistant Chairman. Department of Pediatrics. Charlotte 
Memorial Hospital and Medical Center, Chariotte, N.C 
and Clinical Associate Professor of Pediatrics, University of 
North Carolina School of Medicine. Chapel Hill, N,C. 
Repnnt requests to Dr. Schwartz at Charlotte Memorial 
Hospital and Medical Center, P.O. Box 32861, Charlotte, 
N.C, M232 



July 1981, NCMJ 



low T4, yet euthyroid clinical status, 
he was referred for further evalua- 
tion. 

There was no history of lethargy, 
personality change, cold intoler- 
ance, or constipation. Early de- 
velopmental landmarks were ap- 
propriate. He was an "average" 
student in the fifth grade. He was on 
no drugs or medications. There was 
no family history of thyroid disease. 
Physical examination revealed a 
moderately obese, alert white male. 
His weight was 102Vi lbs. (93rd per- 
centile), and his height was 135.5 cm 
(25th percentile). The pulse was 80, 
and blood pressure 105/65. 

Skin was normal in texture. There 
was no myxedema. The thyroid 
gland was normal to palpation. 
Genital development was Tanner 
Stage II. Deep tendon reflexes were 
normal without delay in the relaxa- 
tion phase. 

LABORATORY RESULTS 

The laboratory data on the patient 
and his immediate family is pre- 
sented in Table I. Findings on the 
patient included a low T4 with an 
elevated T3 resin uptake. TSH was 
normal. A TBG level (RIA, Mayo 
Medical Laboratories) was de- 
creased. Total protein was 7.3 



gm/dl; albumin was 4.3 gm/dl. Bone 
age x-ray of the hand was consistent 
with chronological age. 

A screen of other family members 
included a 9-year-old male sibling 
and the patient's mother, both of 
whom were also clinically euthy- 
roid. The brother had identical 
findings of low T4, elevated T3 resin 
uptake, normal TSH, and a low 
TBG. Maternal studies were bor- 
derline low. 

DISCUSSION 

Transport of thyroxine in vivo is 
accomplished through binding with 
plasma proteins. The majority of 
thyroxine is bound to TBG and 
lesser amounts are bound to preal- 
bumin and albumin.' 

Quantitative abnormalities in 
TBG have been well-described. 
Elevated levels of TBG may be sec- 
ondary to estrogens or perphena- 
zine.^ TBG is also elevated in preg- 
nancy and in neonates. Hereditary 
elevations of functionally normal 
TBG usually occur as an X-linked 
dominant disorder. ^'^ Thyroid 
function studies in these individuals 
and in those with drug-induced ele- 
vations in TBG show increased T4 
values with depressed T3 resin up- 









TABLE 1 














CALCULATED 














FREE T, 








TEST 


TOTAL T, 


T, UPTAKE 


INDEX 


TSH 


T, BY RIA 


TBG BY RIA 


Patient (lOyrs) 


2.0 jtg'di 


557% 


1.11 


4 (lU/ml 


71 ng/dl 


7 ng/dl 


Patients Brother 


2.3 (tg/dl 


55.8% 


1.28 


3MU/ml 


76 ng/dl 


6 fig/dl 


Patient's Mother 


s.s^g/di 


40.0% 


2.20 


4/iU/ml 


95 ng/dl 


14/ig/dl 


Adult Normal Range 


4.5-12.5 Mg/dl 


25-35% 


1.12-4.37 


<10 nU/ml 


98-168 ng/dl- 


16-25 ^g/dl 


10 yr Normal Range 


6.4-13.3 fig/dl 


25-35% 


1.60-4.65 


<10nU/ml 


108-178 ng/dl 


similar to adult 



'Assuming 30 yr adult {Tt normal are age related) 



475 



take reflecting an increased number 
of thyroxine binding sites on TBG. 

Decreased levels of TBG also in- 
fluence thyroid function studies. 
Androgens and prednisone have 
been shown to depress TBG levels. 
Phenytoin is associated with de- 
creased thyroxine binding capacity 
of TBG.- Laboratory studies in in- 
dividuals taking this drug show a 
low T4 with an increased Ts resin 
uptake reflecting decreased binding 
sites on TBG or TBG deficiency. 

Families with TBG deficiency, 
usually as an X-linked dominant 
disorder, have been reported.'' " 
Marshall, Levy and Steinberg^ 
studied a 38-member kindred in- 
cluding six clinically euthyroid 
males with TBG deficiency. Eight 
females in the same kindred had 
laboratory findings consistent with 
an intermediate deficit in TBG: bor- 
derline low PBI or borderline ele- 



vated T3 resin uptake, or both. Be- 
cause of our patient's low T4, ele- 
vated Ts resin uptake, and 
euthyroid clinical status, TBG defi- 
ciency was suspected and con- 
firmed by determination of TBG. 

Screening programs for congeni- 
tal hypothyroidism have shown an 
incidence of TBG deficiency of 
1:7900." More neonates with this 
deficiency will be found as thyroid 
screening becomes more common. 
The initial thyroid function tests or- 
dered should always include a T3 
resin uptake along with a T4 to pre- 
vent the treatment of euthyroid in- 
dividuals who have quantitative 
TBG abnormalities. A TBG level 
can be obtained to confirm the diag- 
nosis. 



Ingbar SH, Woetwr KA; The thyroid gland. In Wilharas 
RH: Textbook of endocrinology, ed 5. Philadelphia. 
W. B. Saunders Co.. 1974. pp. 95-232. 



2. Igo RP. Mahoney CP: Evaluation of the thyroid gland. 
In Kelley V: Metabolic, endocrine, and genetic disor- 
ders of children, ed- 1. New York. Harper & Row. Inc.. 
1974. pp 417-440. 

3- Jones JE. Seal US: X-chromosome linked inheritance of 
elevated thyroxme-binding globulin. J Clin Endocrinol 
27:1521-1528, 1967. 

4. Refetoff S, Robin Nl. ,\lper CA: Study of four new 
kindreds with inherited thyroxine-binding globulin ab- 
normalities. J Clin invest 51:848-867. 1972. 

5. Marshall JS. Levy RP, Steinberg AG: Human thyrox- 
ine-binding globulin deficiency. N Engl J Med 
274:1469-1473, 1966. 

6. Kraemer E, Wiswell JG: Familial thyroxine-binding 
globulin deficiency. Metabolism 17:260-262, 1968. 

7. Nusynowitz ML, Clark RF. Strader WJ. et al: Thyrox- 
ine-binding globulin deficiency in three families and 
total deficiency in a normal woman. Am J Med 50:458- 
464, 1971. 

8. LaFranchi SH. Murphey WH. Foley TP. et al: Neonatal 
hypothyroidism detected by the northwest regional 
screening program. Pediatncs 63:180-191. 1979. 



Acknowledgments 

The authors are grateful to Kirk Johnson in 
the Department of Nuclear Medicine at 
Charlotte Memorial Hospital and Medical 
Center and Dr. Clara Heise of the Depart- 
ment of Nuclear Medicine at Bowman Gray 
School of Medicine for performing the 
thyroid function tests. The TBG assay was 
performed at the Mayo Medical Laboratories 
and Dr, Heise's laboratory. The technical 
assistance of Martha Sue Keasler is also ac- 
knowledged. 



» 



476 



Vol. 42, No. 7 



Hymenoptera Venom Allergy — From the 

Immunology Research Laboratory 

to Clinical Practice 



Donald R. Hoffman, Ph.D. 



DNLY a few years ago the state 
of the art of stinging insect al- 
ergy consisted of diagnosis by in- 
radermal skin testing with an ex- 
;ract prepared by grinding up whole 
insects — usually a mixture of honey 
bees, yellow jackets and hornets — 
and treatment consisted of a series 
of injections of these same extracts 
until an arbitrary maintenance dose 
was reached.' Most authorities 
claimed this therapy was over 959?^ 
effective and cited retrospective 
and statistical studies to support 
their claims.' Laboratory studies 
from several institutions had shown 
that the "relevant" antigens were 
present in these extracts and that 
these antigens were extremely cross 
reactive. However, several inves- 
tigators had questioned the diag- 
nostic value of the intradermal skin 
test with whole body extract 
(WBE), since many patients with 
convincing histories of sting 
anaphylaxis gave negative skin tests 
and patients with no histories of 
sting reactions or even of being 
stung gave positive skin tests.' 
Many allergists treated patients on 
the basis of history alone without 
confirming tests. A few voices were 
heard questioning the prevalent 
standard, but these were dismissed 
by most as a fringe element. 

In 1973, afour year old boy with a 



Associate Professor of Pathology and Laboralory Medic 
tasi Carolina University School of Medicine 
Greenville. N.C, 27834 



July 1981, NCMJ 



history of two almost fatal reactions 
to honey bee stings, the second 
reaction following a course of whole 
body extract therapy, was seen by 
Lichtenstein, et al.^ The boy's sister 
had previously died from bee sting 
anaphylaxis and the risk of ex- 
posure was extremely high, since 
the father was a commercial 
beekeeper. It had been noted previ- 
ously that beekeepers, who are 
stung regularly, rarely have allergic 
reactions to honey bee stings. The 
father collected bee venom and the 
venom was sterilized and used to 
attempt to desensitize the patient by 
doubling the dose every 20 to 30 
minutes. At the equivalent of V3 
sting the boy experienced systemic 
symptoms and the reaction became 
severe at one sting equivalent or 50 
meg. Repeated injections caused 
repeated reactions. The patient was 
then placed on a slower protocol re- 
quiring two months of injections. 
After he had reached a top dose of 
100 meg, he was intentionally stung 
without incident. Serological stud- 
ies showed a substantial rise in IgG 
anti-venom titer had occurred dur- 
ing the two months of therapy.'' 

At this point it became respect- 
able to question the efficacy of 
whole body extract immunotherapy 
and several laboratories undertook 
experiments with venom. Venom 
from honey bees was relatively easy 
to obtain by the use of an electric 
shock grid placed under hives. The 
venom from vespids, yellow jackets 



and hornets, and from paper wasps 
was much more difficult to obtain, 
since these insects must be obtained 
in the wild and the use of the electric 
shock system tends to anger all the 
insects in a large area. It was found 
that an enriched preparation of 
venom could be prepared from 
venom sacs of frozen insects, which 
allowed collection in the wild. The 
procedure is still laborious and ex- 
pensive, and there is only one major 
supplier in the world at present. 

Since venom was to be a phar- 
maceutical preparation, it was nec- 
essary to perform clinical trials to 
verify efficacy as a diagnostic and 
therapeutic agent and to charac- 
terize the material for purposes of 
toxicology and standardization. 
The most thorough biochemical in- 
vestigation was performed on 
honey bee venom since it was avail- 
able in a highly purified form. Five 
significant allergens were isolated 
and characterized and they rep- 
resented virtually all of the venom 
protein. ''■^ These allergens are the 
enzymes acid phosphatase, hyal- 
uronidase and phospholipase A2; a 
protein called allergen C and the 
basic polypeptide melittin. Other 
peptides in the venom were found to 
be non-allergenic. The other ven- 
oms were also found to have multi- 
ple allergens including phospholi- 
pase s, hyaluronidases and a protein 
called antigen 5.^-^ The vespid and 
wasp venom proteins were much 
less stable than those from honey 

477 






Disc-allergen-lgE complex 



Allergen coupled Patient sample containing 

to paper disc both allergen - specific and 

allergen-non-specific IgE 

Disc-atlergen-igE complex Anti-lgE- ' I 



^\'^- 







Allergen-non-specific igE 

St 



'^'llW'y 






Disc-allergen-lgE-anti-IgE- ' I complex 



Figure 1. The Radioallergosorbent Test or RAST. 



bee venom. Toxicological investi- 
gation showed that the LDso was 
about 5 mg/kg for mice by an in- 
travenous route and that the venom 
was less toxic by intradermal and 
subcutaneous routes. Other toxi- 
cological investigation showed 0.1 
mg doses of venom caused no sig- 
nificant pathology. A major retro- 
spective study using multiply stung 
beekeepers as subjects showed that 
this group was apparently healthier 
than a random sample of the non- 
stung population.*^ 

Several centers investigated the 
use of venom as a diagnostic rea- 
gent. Intradermal skin tests using 
venom at a maximum concentration 
of 1 mcg/ml were found to correlate 
highly with histories of recent reac- 
tions to stings." Higher venom con- 
centrations gave positive tests in 
control subjects. Venom skin test- 
ing also showed specificity for the 
insect clearly distinguishing be- 
tween bee, vespid and paper wasp 
and in many cases differentiating 
among the vespids. Various whole 
body extracts were found to give 
poor discrimination between sensi- 
tive and non-sensitive individuals.'" 
Venom was also evaluated in the 
radio-allergosorbent test or RAST 
(Figure 1) as an in vitro diagnostic 
tool. Correlations of RAST with 
clinical history and venom skin test 
of from 80% to 95% were demon- 
strated for each of the venoms. "■'- 
The insect specificity observed by 
skin test was confirmed by RAST 

478 



Studies. Whole body extract was a 
much less potent antigen in RAST 
and correlated more with previous 
WBE treatment than with venom 
sensitivity.'" Histamine release 
from patient basophil leukocytes 
was also tested with venom and 
venom proteins as allergens and 
was found to correlate highly with 
clinical history, venom skin test and 
venom RAST.'^ 

The first scientific evidence for 
the efficacy of venom immuno- 
therapy was provided by Hunt, et 
al'^ whose venom allergic patients 
were evaluated by skin test, RAST 
and histamine release into three 
matched groups. Group I received 
immunotherapy with the venoms 
indicated by skin test. Group II re- 
ceived therapy with whole body 
extract and Group III received 
placebo. Group I was treated to a 
maximum dose of 100 meg venom. 
Group II up to 0.3 ml of 1 : 10 extract 
per injection and Group III was 
given a dose of histamine giving a 1 
cm wheal each injection. The pa- 
tients were then challenged by sting 
with the appropriate insect. Sys- 
temic reactions occurred in 7 of 12 
placebo treated patients, 7 of 1 1 pa- 
tients treated with WBE and only 1 
of 18 treated with venom. Several of 
the reactions in Group II and III 
patients were extremely severe. 
The single reaction in a venom 
treated patient was only mild ur- 
ticaria. On statistical analysis the 
reaction rates for patients treated 



with placebo and WBE were similar 
indicating no efficacy for WBE 
treatment. Venom treatment was 
highly successful. Several labora- 
tories have since examined the 
venom content of both commercial 
and freshly prepared WBEs and 
found them to contain less than 1% 
of the venom dose needed to pro- 
vide protection. Because of the se- 
vere reactions encountered during 
sting challenge of placebo and WBE 
treated patients in the Hopkins 
study, other investigators have not 
performed challenges in controlled 
studies. However, at least three 
groups have sting challenged venom 
treated patients and demonstrated 
that about 90%-95% are protected 
by a monthly maintenance dose of 
100 meg of venom. Most of the fail- 
ures at this dose are protected by 
doubling the maintenance dose to 
200 meg. However, venom treat- 
ment is accompanied by a signifi- 
cant risk of systemic or large local 
reactions during therapy. Adverse 
reaction rates of 15% to 35% have 
been reported by various groups, 
but all the systemic reactions have 
been readily controlled with 
epinephrine.'"' 

Venom allergy is an excellent 
model system for the study of im- 
munologic parameters in allergy. 
Other allergies like pollen or mold 
induced hayfever and asthma are 
difficult to evaluate objectively 
since laboratory challenges poorly 
reproduce the natural exposure and 
usually require at least a thousand 
times more antigen than the natural 
route. Several poorly understood 
variables including extraction and 
absorption of antigen, possible local 
IgE production and threshold ef- 
fects further complicate studies. In 
venom allergy the allergen is natur- 
ally injected into the skin and/or cir- 
culation. Exposure is almost always 
recognized by the patient since the 
sting is painful. It is possible to 
sting-challenge the patient with live 
insects in the laboratory exactly 
duplicating the natural exposure. 

Two immunological parameters 
have been found to be significant in 
determining whether an individual 
is clinically sensitive to venom and 
whether a previously sensitive indi- 
vidual is protected from venom al- 

VOL. 42, No. 7 





2b 





Figure 2. Some stinging insects of importance 
in Nortli Carolina. Honey bee — apis mellifera 



(upper left); yellow jacket — Vespula squa- 
mosa (upper right); white faced hornet — 



lergy. Almost all persons clinically 
allergic to a stinging insect venom 
have elevated levels of IgE antibody 
against that venom in their serum 
and have venom specific IgE anti- 
body on their basophils and mast 
cells as demonstrated by histamine 
release and skin testing. ^■^■''•"■'■' 
Both previously sensitive individu- 
als who tolerate sting challenges 
following immunotherapy with 
venom and often-stung beekeepers 
who have elevated levels of bee 
venom specific IgE but do not react 
to stings have increased venom 
specific IgG antibodies in their 
sera. *'^"' This led to the postulates 
that IgE antibodies are sensitizing 
and that IgG antibodies are protec- 
tive, the so-called "blocking anti- 
bodies" proposed by Cooke.'' 

Several experiments have been 
performed to test this hypothesis. In 
the most courageous experiment 
untreated honey bee sensitive indi- 
viduals were sting challenged. Sev- 
eral who reacted to the challenge 
were infused with gamma globulin 

July 1981, NCMJ 



prepared from beekeepers who 
were regularly stung without ad- 
verse reaction. The gamma globulin 
pool contained a high titer of anti- 
body against bee venom phospho- 
lipase A. After infusion the subjects 
were challenged again and all toler- 
ated substantially higher doses than 
those causing initial reactions."* 
Retrospective studies of patients on 
venom immunotherapy have shown 
that many who react to sting chal- 
lenge do not show a significant level 
of IgG antibody to venom. '■'^ In 
another study it was shown that pa- 
tients allergic to honey bee venom 
who reacted to sting challenge after 
venom immunotherapy had lower 
IgG: IgE ratios to three or more of 
the five bee venom allergens than 
patients who did not react to chal- 
lenge.''' 

As a result of these studies venom 
from the five most important sting- 
ing insects — honey bees, yellow 
jackets, yellow hornets, white faced 
hornets and paper wasps — has been 
approved by the Food and Drug 



2d 



Dolichovespula maculata flower left); paper 
wasp — Polistes exclamans (lower right). 



Administration and is sold by two 
allergen manufacturers. However, 
there are important questions still to 
be answered. How does one deter- 
mine if a given individual will ex- 
perience a severe reaction? Will a 
particular patient lose his sensitivity 
over a short time? Are the reactions 
to multiple venoms commonly ob- 
served indicative of cross-reactivity 
or of multiple reactivity? Should 
one treat the patient with negative 
or equivocal skin test (or RAST)? Is 
the skin test negative patient with a 
convincing history a candidate for 
treatment? What is the relation of 
large local reactions (angioedema 
contiguous with the sting site) to 
systemic reactions? Should all sys- 
temic reactions be treated? Should 
treatment be stopped? Perhaps 
these and other questions can be an- 
swered in the next few years. 

Honey bees, several species of 
yellow jackets, yellow hornets, 
white faced hornets and several 
species of paper wasp are common 
in North Carolina and all cause 

479 




VESPID POLISTES 

USA (1005) 




USA (622) 




VESPID POLISTES 

NC-VA (215) 




NC-VA (160) 



Figure 3. Distribution of allergic reactivity to 
stinging insect venoms in the United States and 
in North Carolina and Virginia.^" The num- 
bers in the Venn diagrams are percent reac- 
tivity to that venom or combination of venoms. 



venom allergy. Four are shown in 
Figure 2. The distribution of reac- 
tivity to the five venoms for 215 
venom allergic patients is shown in 
Figure 3.-" There is less honey bee 
venom reactivity and more Polistes 
venom reactivity in North Carolina 
than in most areas of the United 



States. Another important stinging 
insect in our southeastern counties 
is the imported fire ant of the genus 
Solenopsis. The venom of this 
hymenopteran consists mainly of 
water insoluble alkaloids but also 
contains traces of at least three 
highly allergenic proteins.-' This in- 
sect is not found in the northern or 
western parts of North Carolina, 
but is a significant cause of allergic 
reactions where it is found. Each 
year two to three people die from 
insect venom anaphylaxis in North 
Carolina. 

References 

1. Barr SE: Allergy to hymenoptera slings. JAMA 
228:718-720, 1974. 

2. Brown H. Bemton HS: Allergy to the hymenoptera: 
clinical study of 400 patients. Arch Intern Med 
125:665-669, 1970. 

3. Lichtenstein LM. Valentine MD, Sobotka AK: A case 
for venom treatment in anaphylactic sensitivity to 
hymenoptera sting. N Engl J Med 290:122.1-1227, 1974. 

4. Hoffman DR. Shipman WH: Allergens in bee venom 1. 
Separation and identification of the major allergens. 
J Allergy Clin Immunol .58:551-56:. 1976. 

5. Hoffman DR. Shipman WH, Babin D: Allergens in bee 
venom II, Two new high molecular weight allergenic 
specificities. J Allergy Clin Immunol 59:147-153, 1977, 

6. Hoffman DR: Allergens in hymenoptera venom V, 
Identification of some of the enzymes and demonstra- 
tion of multiple allergens in yellow jacket venom, Ann 
Allergy 40:171-176, 1978, 

7. King TP, Sobotka AK. Alagon A, et al: Protein al- 



io 



11 



lergens of white-faced hornet, yellow hornet and yellow 
jacket venoms. Biochemistry 17:5165-5174, 1978, 
Yunginger JW, Jones RT, Leiferman KM, et al: Im- 
munological and biochemical studies in beekeepers and 
their family members, J Allergy Clin Immunol 61:93- 
101. 1978, 

Hunt KJ, Valentine MD, Sobotka AK, Lichtenstein 
LM: Diagnosis of allergy to stinging insects by skin 
testing with hymenoptera venoms. Ann Intern Med 
85:.56-59, 1976. 

Light WC, Reisman RE, Rosano NA. Arbesman CE: 
Comparison of the allergenic properties of bee venom 
and whole bee body extract. Clin Allergy 6:293-300, 
1976. 

Hoffman DR: The use and interpretation of RAST to 
stinging insect venoms. Ann Allergy 42:224-230, 1979. 

12, Hoffman DR: Comparison of the radioallergosorbent 
test to intradermal skin testing in the diagnosis of sting- 
ing insect venom allergy, Ann ,\llergy 43:21 1-213, 1979. 

13, Sobotka AK, Valentine MD, Benton AW, Lichtenstein 
LM: Allergy to insect stings 1. Diagnosis of IgE 
mediated hymenoptera sensitivity by venom-induced 
histamine release. J Allergy Clin Immunol 53:170-184, 
1974. 

Hunt KJ, Valentine MD, Sobotka AK, et al: A con- 
trolled trial of immunotherapy in insect hypersensitiv- 
ity, N Engl J Med 299:157-161, 1978, 
Lichtenstein LM. Valentine MD, Sobotka AK: Insect 
allergy: the state of the art, J Allergy Clin Immunol 
64:5-12, 1979, 

Light WC Reisman RE. Wypych JI, Arbesman CE: 
Clinical and immunological studies of bee keepers, Clin 
Allergy 5:389-395, 1975. 

17. Cooke RA, Barnard JH, Hebald S, Stull A: Serological 
evidence of immunity coexisting with sensitization in a 
type of human allergy (hay feverl. J Exp Med 62:733- 
751. 1935. 

Lessof MH, Sobotka AK, Lichtenstein LM: Effects of 
passive antibody in bee venom anaphylaxis, Hopkins 
Med J 142:1-7, 1978, 

19. Hoffman DR. Gillman SA. Cummins LH. et al: Corre- 
lation of IgG and IgE antibody levels to honey bee 
venom allergens with protection to sting challenge. Ann 
Allergy 46:17-23. 1981. 

Hoffman DR. Miller JS. Sutton JL: Hymenoptera 
venom allergy: a geographic study. Ann Allergy 
45:275-279, 1980, 

Baer H, Liu TY, Anderson MC, et al: Protein compo- 
nents of fire ant venom (Solenopsis invicta), Toxicon 
17:397-405, 1979, 



14 



15 



16 



18 



20 



'■ 



480 



Vol, 42. No. 7 



SPECIAL ARTICLE 

Message of the President 

to the 

House of Delegates 



M. Frank Sohmer, Jr., M.D. 
May 7, 1981 



I 



T has been a distinct honor and 

pleasure for me to serve as your 
president since this House of Dele- 
gates last convened here in May, 
1980. 

Three years ago. Dr. Estes 
pointed out in his address to you 
here "one day the job begins." He 
failed to mention it begins with a 
loud consuming "BANG." The 
housekeeping tasks are significant, 
i.e. appointing 40 plus committees, 
their meetings, the monthly news- 
letters, etc. While demanding, time 
consuming and at times frustrating, 
it has been a very worthwhile ex- 
perience to be allowed to represent 
you and the membership. I thank 
you again for the opportunity and 
honor. 

1 am pleased to report to you that 
I believe the North Carolina Medi- 
cal Society to be hale and hearty. 

The membership of your society 
in April, 1981, was 5,701: an in- 
crease of 282 members since April, 
1980. The North Carolina AMA 
membership in April, 1981, was 
4,392, an increase of 181 members 
over April, 1980. The North Caro- 






Giver before the House of Delegates. North Carolina Medi- 
cal Society, Pinehurst. N.C., May 7, 1981. 



July 1981, NCMJ 



lina Medical Society membership 
on January 1, 1981, was 5,745, only 
75 new North Carolina Medical So- 
ciety members in 1980. It is I think 
of interest to note AMA mem- 
bership rose to 4,420: a net gain of 
North Carolina AMA members of 
109 in 1980. 

At the National AMA Leadership 
Conference, North Carolina Medi- 
cal Society was one of five states to 
receive a plaque to recognize in- 
creased AMA membership for the 
8th consecutive year. 

The Board of Medical Examiners 
has reported licensing 966 physi- 
cians in essentially the same time, 
not including 491 residents training 
licenses. If we assume one-half of 
these newly licensed physicians 
began practice in North Carolina, 
(483 physicians), the net gain of 75 
new members would suggest we are 
at a crucial time for membership. I 
hope our new leadership, this 
House of Delegates, the Executive 
Council and especially the Council 
of Review and Development will 
devote their attention to this im- 
portant area. I encourage all of you 
to invite the non-member physi- 
cians in your community to join 
with organized medicine locally, in 
our state and nationally in order to 
grow in numbers and strength to 



represent and preserve the profes- 
sion. 

The three-year continuing medi- 
cal education (CME) cycle which 
ended December, 1980, lists the 
most members to date, 3,407, 191 
members have not completed their 
reporting; of these 70 have sub- 
mitted partial reports. I must make 
you aware that of the 5,701 North 
Carolina Medical Society members 
in April '81, 119 have paid and are 
counted but have not completed 
their CME requirements for mem- 
bership. The Executive Council, in 
April, deferred action until May 31 
on the suspension of these mem- 
bers. This is to allow the House of 
Delegates to consider resolution 
#10 on the subject of CME. 

Under the able leadership of your 
finance chairman. Dr. Ernest 
Spangler, the financial status of the 
society is good. Income was 
$1,029,000 with expenditures of 
$977,000. 

The 1981 Annual Budget (Report 
B) is in your packet. This, as well as 
the recommendations of the Fi- 
nance Committee as approved by 
the Executive Council (Report 1), 
will be discussed in Reference 
Committee I. There is no recom- 
mendation for a dues increase this 
year. 

481 



Your Executive Council has met 
five times this year; September, 
February, April and last night and a 
conference call in September. As a 
result of the conference call, I gave 
testimony to the Prepaid Health 
Plans Commission reaffirming to 
the Commission the North Carolina 
Medical Society's opposition to 
government funding of Association 
Health Maintenance Organizations 
(HMOs) and Independent Proce- 
dure (IPAs). To date neither Gover- 
nor Hunt nor the Legislature has 
acted on the Commission Report. 
Some additional actions of the 

Council, acting on your behalf in the 

interim, follow: 

1. (Report A) Dispense with ver- 
batim council minutes, summariz- 
ing with introductory information, 
motions and actions being re- 
corded. This action was reaffirmed 
at the April Council meeting. This 
Report, as well as Resolutions 3 and 
9, on this subject, will be discussed 
in Reference Committee I. 

2. Approved the employment of 
the management consulting firm 
Booz, Allen & Hamilton of Atlanta 
to study the operations of the North 
Carolina Medical Society. 

3. Approved the Annual Conven- 
tion Committee's tentative reser- 
vation in Charlotte for the 1983 An- 
nual Meeting. 

4. Approved continuing the 
North Carolina Medical Society 
sponsored jail project through 1981, 
although AMA support funds will 
expire after May. 

5. Directed documentation of the 
Administrative Code for the Medi- 
cal Society Operation. This ad hoc 
committee, chaired by your Vice 
President, Tom Marshburn, is hard 
at work. 

Other actions are indicated in the 
lettered Reports and Executive 
Council Summaries in your packet. 
I would specifically request and 
urge all of you to read the three 
summaries of Executive Council 
meetings, as well as the Compila- 
tion of Annual Reports. 

The Communications Commit- 
tee , under the able leadership of Dr. 
Elizabeth Kanof, has been very ac- 
tive this year. The Leadership 
Conference in February was an ex- 
ample of this committee's excellent 



work. Please plan to attend the 1982 
Leadership Conference in Win- 
ston-Salem in Feburary. 

I cannot in any reasonable fash- 
ion in the time allowed report to you 
on all the outstanding and excellent 
work of the hardworking and dedi- 
cated committee chairmen and their 
committee members. Any attempt 
to single out specific committees, 
outstanding chairmen, the ac- 
complishments, the efforts and 
work would be very unfair unless 
time permitted individual consid- 
eration. Time does not permit so I 
say a great BIG thank you! 

Please do take the time to read the 
compilation and recognize that this 
is only a brief summary. The head- 
quarters' staff does an outstanding 
job in supporting all of these func- 
tions. 

Your AMA Delegation continues 
to represent us very well at the 
AMA House of Delegates. It is with 
the deepest regret that I must make 
you aware that the Chairman and 
Dean of the Delegation, Dr. David 
Welton, who has served this Soci- 
ety so well and long, will not stand 
for re-election as a delegate this 
year. I am sure you support me 
when I express our deepest ap- 
preciation to Dave for a job better 
than well done. We wish him good 
health and every happiness in the 
years to come. 

We continue to have excellent 
input with the AMA with your past 
President and Delegate, Dr. John 
Glasson, serving as Chairman of the 
Council on Medical Services and 
Dr. Eben Alexander, serving on 
Council of Medical Education. I am 
pleased to report that Dr. Jim Davis 
will be a candidate for the Vice 
Speaker of the AMA House of Del- 
egates in June. Dr. Harvey Estes 
will be a candidate for the Council 
on Scientific Affairs. We wish them 
both success in their candidacies. 

I would like to spend a few min- 
utes on legislative matters. Par- 
ticularly to express my deep admi- 
ration and appreciation to our very 
dedicated Legislative Committee 
chairman. Dr. John Dees who has 
done an outstanding job! 

Dr. Dees has been aided and sup- 
ported ably by our Legislative staff 
members, Tom Adams and John 



Anderson, legal counsel and his as- 
sociates. 

Over 450 key contact physicians 
and auxiliary members have com- 
bined their efforts to create a very 
effective force in behalf of the citi- 
zens of North Carolina and the 
profession. We extend our appreci- 
ation to all concerned. A number of 
physicians have upon request at- 
tended legislative hearings and 
given testimony in your behalf in 
Raleigh. Thanks to each of you for 
your most able assistance on such 
short notice. 

Some of the pending legislative 
issues that have been handled in this 
manner follow: 

1. A new Chiropractic Bill, simi- 
lar to the 1979 proposal, to define 
chiropractors as primary care pro- 
viders, etc. 

2. Podiatry and Hospital Staff 
privileges. 

3. Licensing of midwives and 
home deliveries. 

4. Rewriting of the Pharmacy 

Act. 

5. Rewriting of the Nurse Practice 
Act. 

6. Repeal of the previous legisla- 
tive relief in professional liability 
area. 

7. The revision of the Board of 
Medical Examiners. 

8. Rate Setting Commission for 
hospitals. 

9. Mandatory reporting to parents 
of minors obtaining abortions. 

10. Generic drug substitution. 
Several other issues are covered 

in Report 7. The activities of Dr. 
John Dees, his committee and the 
many individuals in supporting 
roles, utilizing the incoming WATS 
line, the weekly Legislative update 
letter, the Legislative alerts, the key 
contact physicians and auxiliary 
members have been very pleasing 
to me so believe me when I say very 
valuable to you also. 

In closing, I wish to thank the six 
Commissioners, my fellow officers 
and members of the Council for 
their help and support this year. 
Without them, the year would have 
been a disaster. 

Finally, I want to express my ap- 
preciation to Mr. William Hilliard 
and our Headquarters staff for their 
excellent support to the Society this 
year. 



482 



Vol. 42, No. 7 



SPECIAL ARTICLE 

Annual Address of the President 



M. Frank Sohmer, Jr., M.D. 
May 9, 1981 



WHEN 1 had the honor of as- 
suming the office of President 
of the North Carolina Medical Soci- 
ety one year ago, I spoke to you 
briefly on the subject of social con- 
sciousness. At that time, I stated 
that our first duty and responsibility 
was as a citizen in this great country 
of ours. That charge I would repeat 
to you this morning. In my year as 
your President, I am convinced that 
admonition was and still is correct! 
However, I have observed that a 
significant number of our fellow 
citizens have exhibited little or no 
interest in good government unless 
their particular ox is being gored. 
Despite this, an encouraging num- 
ber of physicians responded to re- 
quests to participate in the Medical 
Society activities and legislative 
endeavors. 

I had felt as the year proceeded 
that I would share with you my 
further thoughts on our responsibil- 
ity as citizens and I feel a greater 
urgency to talk with you today on 
our responsibility to our patients 
and as citizens. 

My feelings are better expressed 
in the first aphorism of Hippocrates 
which reminds us: "Life is short, 
and the Art long; the occasion 
fleeting; experience fallacious and 
judgment difficult. The physi- 
cian must not only be prepared to do 



Given before the Second Genera] Session. North Carolina 
Medical Society, Pinehurst. N.C., May 9. 1981. 



what is right himself, but also to 
seek the cooperation of the pa- 
tient." As the year has progressed, I 
have seen and had expressed to me 
a deplorable deficiency in practicing 
the Art of Medicine. 

I have perceived an apathy that 
bodes ill for the future. 

This apathy or lack of interest 
seems even to have pervaded our 
profession in patient/physician re- 
lationships. I see patients each 
week who cannot remember the 
name of the last physician who pro- 
vided care the week before nor who 
performed the surgery in the past or 
for what. The ability to communi- 
cate with the public and to our pa- 
tients is being lost. I have to believe 
then some of the Art of Medicine 
has been lost. Technically, great 
and wonderful things have occurred 
in my medical life of some 30 years, 
i.e. renal transplants, coronary 
bypass, computerized tomographic 
scans, etc. Is there evidence that 
these advancements have length- 
ened life expectancy? Have they 
been cost effective? Yes, it would 
appear we seem able to provide 
quicker more astute diagnoses and 
effective treatment, but at what cost 
to us and the public? I am concerned 
with the profession becoming more 
technologically dependent and in- 
creasingly less communicative and 
responsive to the patient. As I re- 
flect upon my good fortune and per- 
sonal exposure in the past years to 
skilled clinicians, i.e. Wingate 
Johnson and David Cayer at Bow- 



man Gray, Julian Ruffin and Gene 
Stead at Duke, I remain in awe of 
their Art in Medicine. They ac- 
cepted and advanced the technical 
aspects of medicine, but never lost 
their ability to treat the patient as an 
individual. 

Again, to quote from "The 
Genuine Works of Hippocrates," 
and from his Book of Prognostics: 
"It appears to me a most excellent 
thing for the physicians to cultivate 
Prognosis; for by foreseeing and 
foretelling, in the presence of the 
sick, the past and the future, and 
explaining the commissions which 
patients have been guilty of, he will 
be more readily believed to be ac- 
quainted with the circumstances of 
the sick so that men will have confi- 
dence to entrust themselves to such 
a physician." 

In our profession, the ability to 
listen continues to be of the greatest 
single value. In addition, the best 
physicians take time to then talk to 
the patient and involve the patient in 
his health management. The indi- 
vidual is responsible for his health. 
We, the professionals, must re- 
member that we are not responsible 
for individual's health, but rather 
are consultants to the public in their 
health maintenance. 

I submit to you, however, the 
final determination of the future of 
our fine health care system and our 
learned profession will be made by 
our patients. If we practice the art, 
communicate and are the friends of 
our patients and do not allow apathy 



July 1981, NCMJ 



483 



to replace genuine caring, then we 
will have nothing to fear from the 
bureaucrats, Kennedy types, labor 
leaders and others of their ilk, who 
would destroy the profession and 
the health care system. 

We concern ourselves with the 
recent advent of government 
funded HMOs. Actually, in 1705 in 
Boston, a physician established a 
prepaid health care plan rendering 
care for five pounds a year. Fee 
schedules are not new. In 1744, in 
the North Carolina House of 
Burgesses, a physician introduced a 
fee schedule. The "new" prepaid 
plan IPAs were present in this 
country as early as 1798. When 
ships' captains entered U.S. ports, 
they paid 50^ per crew member for 
health care while in port. From this 
meager beginning, the U.S. Public 
Health Service emerged. Railroads 
utilized contracted physicians along 
their lines in opening the West, 
another example of IPAs. 

It would appear that the intent of 
President Reagan's administration 
may be to remove the Federal gov- 
ernment from the health planning 
arena. We must be prepared to fill 



this vacuum and provide leadership 
for voluntary local health planning. 

PSRO is another program that 
may not survive in the present cli- 
mate. Again, we must prepare to 
respond voluntarily on a local level 
to the need for peer review and ac- 
countability. We have the responsi- 
bility to assure the public that their 
faith and trust in the medical profes- 
sion is correct and that we treasure 
this most highly. 

In the past decades, we have pro- 
vided excellent service and care to 
the sick. We must increasingly now 
concern ourselves with more than 
sickness care. We must provide 
health care, which is a much 
broader and most important re- 
sponsibility. As the infectious dis- 
eases are being eradicated, our ef- 
forts have turned to the chronic and 
degenerative diseases. Causes of 
these diseases are much broader 
than the single viral or bacterial 
agents causing the infectious dis- 
eases. The disabling and fatal 
chronic diseases have a multi- 
faceted basis: genetics or biological 
factors, as well as complex social 
factors of poverty, education, envi- 



ronment and personal life styles, 
i.e. tobacco, alcohol, drugs, stress 
and exercise. 

We have the opportunity to fill 
necessary and important roles as 
citizens and physicians. We are 
better able because of special edu- 
cation and acquired experience to 
influence the evolution that must 
occur in our society in this decade. 

Genuine care for those sick, con- 
cern to help maintain the health of 
those well, leadership in the legisla- 
tive and social arenas to help direct 
our society with total integrity and 
not self interest or self aggrandize- 
ment will, as stated earlier, result in 
what will be best for all of us and our 
fellow citizens. Do this with the 
dedication of our forebears in medi- 
cine so that we may leave to sub- 
sequent generations of physicians 
the same wonderful opportunities 
to serve as we have enjoyed. // is 
lip to us. We have the opportu- 
nity and we must embrace it. We 
must be more positive and assertive 
in our role as custodians of the 
health of our fellow citizens and as 
citizens in our great country. We 
must not forfeit our heritage. 



484 



Vol. 42, No. 7 



Special Article 

Attachment of a Physician's Assistant 
To an English General Practice 

B. L. E. C. Reedy, T. I. Stewart, J. B. Quick 



SUMMARY AND CONCLUSIONS 
A final-year student from tlie pliysi- 
cian's associate programme at Duke 
University in Nortli Carolina, USA, 
worked in an English health centre 
for eight weeks between May and 
July. He managed 221 cases under 
supervision, and they were typical in 
terms of sex ratio, diagnosis, and the 
preponderance of children. Current 
social and economic trends in Britain 
suggest that selective under-doctor- 
ing, especially in inner urban areas, 
may become acute, and a type of 
physician's assistant specially 
selected and trained for the work in 
areas with serious and unusual 
problems should be considered as 
among the possible, even desirable, 
solutions. 

INTRODUCTION 

IN an attempt to reverse the de- 
cline of general practice in 
America, Duke University started 
in 1965 to train assistants for pri- 
mary care physicians in the rural 
areas of North Carolina. Other 
medical schools followed, and by 
1974 the American Medical Associ- 



Reprinled with Permission of the British Medical Journal 
281:664-666. Sept. 6. 1980. 

Medical Care Research Unit, University of Newcastle upon 

Tyne NE2 4AA 
B L E Greedy. MB. MRCGP. senior lecturer 
Sonning Common Health Centre. Reading RG4 9SW 

T 1 Stewart, MB, FRCGP, general practitioner 

Palisade, Colorado, USA 

J B Quick. PA-certified. physician's assistant 



ation had accredited 48 training 
programmes from which some 1200 
"physician's assistants" were 
practising in 36 States.' After grad- 
uation these assistants are em- 
ployed and supervised by a physi- 
cian. In each State they must be 
licensed or certified to practice and 
their autonomy is legally circum- 
scribed. 

In Britain there is no comparable 
problem in the distribution of gen- 
eral practitioners and no explicit 
call for a doctor's assistant. Indeed, 
the idea of a physician's assistant on 
American lines is resisted by the 
BMA-. Nevertheless, there is a de- 
bate about medical manpower, in- 
cluding the development of "ex- 
tended roles" and the contribution 
of other health professionals to the 
medical problems of inner city 
areas. •''■^ It seemed opportune when 
a final-year student at Duke Univer- 
sity asked to spend his family prac- 
tice elective in an English general 
practice, and an attachment was ar- 
ranged with the partners in the 
health centre at Sonning Common, 
one of whom (TIS) acted as his pre- 
cepting physician. 

At Duke University students re- 
ceive two years' training in basic 
and clinical science, including 
history-taking, physical examina- 
tion and practical procedures. A 
problem-solving approach using the 
subjective, objective assessment 
and plan (SOAP) system enables 



them on graduation to " . . . assume 
many of the diagnostic, therapeutic, 
and administrative responsibilities 
traditionally performed only by the 
physician ... to integrate and 
interpret findings on the basis of 
general medical knowledge, and to 
exercise a degree of independent 
judgment.'"' 

All prospective physician's as- 
sistants must have had one year's 
health-related experience before 
training, and this student had 
worked as a hospital emergency 
technician for two years with six 
months in a public health depart- 
ment. As a former mountaineering 
instructor he had also had experi- 
ence in triage and medical care and 
had worked in two family practices 
in America. This experience and 
training was relevant to his work in 
an English health centre practice. 

METHOD 

We found no record of any 
working visit by a physician's as- 
sistant to Britain, and we sought ad- 
vice about the legal and ethical is- 
sues. The General Medical Council 
was concerned about "covering" 
and stipulated that the patients must 
understand that the physician's as- 
sistant was not a registered medical 
practitioner. The Medical Protec- 
tion Society warned that no proce- 
dure should be delegated until the 
doctors were satisfied that he was 
competent to perform it. The hos- 



JULY 1981, NCMJ 



485 



pital liability insurance of Duke 
University covered him against liti- 
gation while in Britain. 

The health centre staff were 
briefed beforehand, and a notice 
was displayed for the patients but 
those who saw him also received a 
written explanation. While working 
he wore his own uniform and pocket 
badge to fulfil the requirements of 
the General Medical Council about 
his identification. After a week in 
the practice his capability was as- 
sessed by the staff for his preceptor 
to gauge his competence for the 
work envisaged. He subsequently 
recorded data about the patients he 
saw by himself, and one of us (BLR) 
interviewed him and the staff about 
their reactions. 

RESULTS 

The physician's assistant spent 
eight weeks in the practice between 
May and July and saw patients on 35 
weekdays. During the first nine 
working days he made himself 
familiar with the staff and proce- 
dures of the health centre. He also 
visited the offices of the area health 
authority, the family practitioner 
committee, and the social services 
department and accompanied the 
district nurse and health visitor. 
After assessment he was treated as 
a trainee general practitioner, with 
the use of a consulting room and all 
facilities including the appointment 
system. 

During the next 26 days, he held 
267 consultations (10.3 a day on av- 
erage) with 221 patients. Of these, 
188 (85%) attended only once, but 
the remaining 33 provided a total of 
79 consultations. Thus there were 
46 repeat consultations, forming 
17% of his overall total. This pro- 
portion did not differ significantly 
from week to week. Twenty-seven 
(10%) of all his consultations were 
with 16 patients in their own homes 
(or in one case in the community 
hospital), although some of them 
also attended at the health centre. 
Thus his ratio of surgery atten- 
dances to visits was 8.9:1.0 com- 
pared with the significantly higher 
rate of 17.7: 1 .0 for the practice as a 
whole during the same period (p < 
0.01). In addition he worked in the 
health centre's diabetic, infant 



welfare, and obstetric clinics and 
shared the work of the treatment 
room nurse. 

The assistant saw more female 
than male patients (57%) and 59% of 
his patients were aged between 15 
and 64 years. The proportion of 
children under 15 (32%) was as ex- 
pected, significantly higher than 
their proportion (22%) in the popu- 
lation of England in 1978.'' There 
was a secular trend whereby the 
proportion of children that he saw 
increased and the proportion of pa- 
tients aged 65 or over diminished 
during his attachment. 

The table shows that the primary 
diagnoses recorded by the physi- 
cian's assistant were broadly simi- 
lar to those recorded nationally." 
After every consultation (excepting 
13 for minor procedures) his pre- 
ceptor routinely reviewed the clini- 
cal record, discussed the findings 
and plan, and signed the prescrip- 
tions. The physician's assistant ac- 
tively sought advice about diagnosis 
or management in only 26% of cases 
but more detailed case discussion 
followed each consulting session, 
and there was a weekly random case 
review. Further monitoring was 
provided by the preceptor's part- 
ners and by feedback from patients 
and staff. Overall, these controls 
added about 15 minutes to each of 
the preceptor's consulting sessions 



and about two hours at the end of 
each week. 

Data from the recorded semi- 
structured interviews showed that 
his acceptability to the staff de- 
pended on the extent of their pre- 
paredness. A treatment room nurse 
who had missed the initial briefing 
said she began by feeling insecure 
and hostile to him, whereas a dis- 
trict nurse who had worked with 
medical assistants abroad accepted 
him without difficulty. The staff 
were impressed by his clinical 
ability after only two years' train- 
ing, and his probationary period 
was reduced from four weeks to two 
because of this. He was judged to be 
more confident and competent than 
most attached medical students and 
some trainee general practitioners, 
particularly in practical procedures, 
and less stereotyped by hospital 
attitudes. He was popular with pa- 
tients and particularly with chil- 
dren, some of whom believed that 
they were seeing a real cowboy! 

Having themselves helped to de- 
velop the extended role for commu- 
nity nurses in Britain,** the general 
practitioners agreed that their expe- 
rience with the physician's assistant 
showed that casual training for 
treatment room and first-contact 
work was insufficient. Practice 
nurses should have a formal training 
that included the theory of scientific 



u 



Primary diagnoses of patients seen by the physician's assistant 











Second 










national 




International 






morbidity 


Diseases 


classification 


Episodes 


survey' 






No 


% 


% 


Respiratory system 


460-519 


27 
38 


29 


22 


Hay fever/allergic rhinitis 


407 






Skin and subcutaneous tissues 


680-709 


23 


10 


8 


Musculoskeletal and connective tissues 


712-739 


17 


8 


6 


Genitourinary system 


580-629 


16 


7 


5 


Ear 


380-387 


13 


6 


4 


Infective and parasitic 


008-136 


12 


5 


4 


Digestive system 


520-578 


10 


5 


4 


Circulatory system 


390-458 


8 


4 


5 


Accidents, poisoning, and violence 


N802-994 


7 


3 


6 


Pregnancy, ctiildbirth, and puerperium 


Y60-62 
631-678 


r 


3 


9 








Mental disorders, central nervous system, and eye 294-378 


5 


2 


12 


Neoplasms 


151-239 


4 


2 


1 


Endocrine, nutritional and metabolism 


240-279 


1 


< 1 


2 


Ptiysical symptoms and signs 


780- 


10 


6 


10 


Miscellaneous conditions 


YOO-99 
{except 
Y60-62) 


24 


11 


2 


Totals 




221 


101 


100 



486 



Vol. 42. No. 7 



ll 

I 



and technical aspects of the work, 
such as chemical pathology and 
electrocardiography, as well as 
practical medical skills. This work 
also requires a reliable system for 
delegation and supervision. But de- 
spite their experience with this as- 
sistant, both general practitioners 
and nurses were doubtful whether 
the American type of physician's 
assistant was appropriate for gen- 
eral use in Britain. Although general 
practitioners were sometimes 
overworked, the creation of a new 
type of health worker did not seem 
justified, except in our urban ghet- 
tos where the local use of medical 
assistants other than nurses might 
enable a primary care service to 
survive. 

The physician's assistant said 
that his prevocational work in 
emergency rooms had taught him to 
deal with minor conditions, and by 
watching the doctors he learned 
how to approach patients and be- 
came familiar with physical exami- 
nation routines. He extolled this ex- 
perience and said: "... you know 
something about what medicine is. I 
think that makes a tremendous dif- 
ference; and the age too — the stu- 
dents that you have here are five 
years younger than I am so far as 
dealing with patients is concerned 
... we all started at a low level and 
had a view of what we were getting 
into. Certainly it is true of [Ameri- 
can] medical students that I know 
that they don't know what they are 
getting into." 

He thought the clinical experi- 
ence in this elective was similar to 
that of family practice in America 
but envied our district nursing ser- 
vice and facilities for monitoring 
and recall in immunisation and cer- 
vical screening. He observed that 
our treatment room nurses ap- 
peared to do much more than the 
"office nurse" in America ^ in- 
deed, more than most American 
nurses outside special treatment 
units. Commenting on the collab- 
oration between the health centre 
staff he said that interest in this was 
growing among American physi- 
cians, despite their tradition of iso- 
lation in this respect. Asked what he 
had gained from his attachment, he 
replied: "Certainly it is right in line 

July 1981, NCMJ 



with what I had hoped for — that is, 
common problems with enough 
things thrown in that are serious or 
unusual and require more thorough 
investigation. I want to be very 
comfortable in dealing with the 
common problems, and I want to 
learn about handling problems that 
are very acute. I have gotten that 
feeling here — the majority have 
been common things which I feel 1 
can pretty well handle myself." 

DISCUSSION 

We believe that this is the first 
time that an American physician's 
assistant has worked at any stage of 
his career in an English general 
practice. Given appropriate safe- 
guards, there were no legal or pro- 
fessional barriers to the attachment, 
but its success depended particu- 
larly on the initial briefing for the 
staff, his preliminary assessment by 
the whole practice, and the infor- 
mation given to prepare the pa- 
tients. 

His cases were typical in terms of 
sex ratio, diagnosis, and the pre- 
ponderance of children. A daily av- 
erage of 10.3 consultations, with 
attendance at clinics, must repre- 
sent an acceptable amount of edu- 
cational experience, and the pro- 
portion of patients he saw at home 
was similar to that recorded both by 
Howie" and by Marsh et al.^" He 
dealt with common acute problems 
rather than the routine examina- 
tions that figure largely in American 
practice,'" and in the circumstances 
this was the most relevant ex- 
perience. His preceptor and the 
other staff were satisfied that the 
information he collected and his as- 
sessments of patients were accu- 
rate, relevant, stood up to scrutiny, 
and enabled management plans to 
be discussed and implemented. De- 
spite his relative inexperience, he 
identified and handled at least one 
patient's major emotional and social 
problem with skill and tact. 

The responses of the nurses and 
health visitor towards him em- 
phasized the essential difference 
between two worldwide stereo- 
types — the physician's assistant 
and the nurse practitioner.' Re- 
gardless of his gender, all the nurses 
saw him as a type of physician, not a 



type of nurse. The treatment room 
nurse, however, recognized that her 
work and role most resembled his, 
thus reinforcing a suggestion that 
these nurses differ in type from 
other nurses and might be said to be 
the "feldshers" of British general 
practice." 

We were convinced that his con- 
fidence and maturity and his ability 
to relate to the members of the 
health centre team as well as pa- 
tients owed much to his prevoca- 
tional experience. Perhaps the for- 
mation of community health care 
teams in Britain could be enhanced 
by a similar initiative among em- 
bryo doctors and nurses, and a 
controlled experiment should be 
carried out in nursing and medical 
schools. Moreover, clearly nurses 
who undertake medical activities in 
British general practice must have 
the generic skills for collecting 
medical data from patients and be 
trained in a level of differential 
diagnosis that at least enables them 
to make an informed "triage" deci- 
sion. '- 

The attachment also convinced 
us that it would be possible in Bri- 
tain to train an auxiliary physician 
to handle considerable proportion 
of the more straightforward cases in 
primary care. At present it seems 
unlikely that auxiliaries of this kind 
would be needed as the result of a 
shortage of doctors, but it is barely a 
decade since the Americans were 
compelled to adopt this as one solu- 
tion to the problem of selective 
under-doctoring affecting their 
inner urban areas, among others. 
Current social and economic trends 
in Britain suggest that the same 
problem may become acute here as 
well, and a type of physician's as- 
sistant specially selected and 
trained for work in areas with seri- 
ous and unusual problems should be 
considered as among the possible, 
even desirable, solutions. 

We thank Dr. Michael Hamilton, director 
of the physician's associate program at Duke 
University Medical Center, for his collabora- 
tion and the Royal College of General Prac- 
titioners and the Wellcome Foundation in 
North Carolina for their supporting grants. 
We are also grateful to Dr. P. M. R. Hem- 
phill, Dr. J. C. Hasler. and Dr. Helen Mc- 
Ewen. together with the nurses, health vis- 
itors, and administrative staff of the Sonning 
Common health centre for their support and 
interest in the attachment. 

487 



References 

1 Reedy BLEC, The new heallh pracli.ioners in Amenca 
- a comparaliye study. London: King Edward^^Hos- 
pital Fund for London. 1978 

2. Grey-Turner E. Doctor manpower. The Times 1977 Mar 

rcia?rs?it°,f^^^sr7^"'''''-"™""^=^'^- 



'" ?,n''/ ^"'"^"''y M'^di'^'J Center. Educational goals and 
Duke nnfv:"";* °t"""''- °"'^^'^- North Carol.n" 
Duke University Physician-s Associate Program 197S 

7. Ofllce of Population Censuses and Surveys. Studies on 
su.1«,csfr,i'""'"''',"'" '"''"'"' ''° 26. Morbtdny 

^s^'trr.T^Ton^'ii';:,^^",'^^?^ ^^^^^ -■''-' -"v 

* "^J.'^JC, Hemphill PMR. Stewart Tl Bovlc N Harris 
A. Palmer E^ Development of the nursing s'ec,k,no?^e 
community health team. Br Med J l%8Ti:734-6 



10, 



Bn.Tsh !? H ^1"*"'^' '" «""^ P™^"« 1977- London- 
Bntish Medical Association. 1977 ""uun. 

Marsh GN. Wallace RB Whew/^ll i a i * 

-">;-•^'^ general pracl.c^irMed nst'f m^"" 

Reedy BLEC, Metcalfe AV. de Roumanie M Neweil 

tache^1?nT""l'" V*"" ""■^"'" ^"d opin^ns of ^ 

Coll t^en ^ ";'^ °>'"' ""''" '" S""^ P^^"i«- F R 
coll Oen Pract (in press) 

Moore ME, Barber JH. Robinson ET, Taylor TR 
First-contact decisions in general practice: a corip™' 
La"ncerr9T3'; i^8?^-T ^"^ '"'' «""^ "-"•--■ 



488 



Vol. 42, No. 7i 



p-Toxic Encounters of the Dangerous Kind-| 
Are Your Patients Speeding? 



Amphetamine abuse appears to be a 
somewhat less serious problem in the 
1980s than it was in the 1970s. The Food 
and Drug Administration is attempting to 
decrease the manufacturing of amphet- 
amines. Meanwhile, cocaine seems to 
have become the sophisticated and more 
expensive drug for getting "high." When 
we seem to be winning a battle in medi- 
cine, another appears to replace it. 
Another nemesis is phenylpropanolamine 
(PPA). 

Whereas amphetamines and cocaine, 
both legally and illegally, are somewhat of 
a bother to obtain, phenylpropanolamine 
is easily available over the counter. This 
drug, a synthetic sympathomimetic agent 
with pharmacologic actions similar to 
ephedrine and amphetamine, is a major 
ingredient of over-the-counter "cold 
remedies" and appetite suppressants. 
There is very little evidence that PPA 
provides sustained suppression of appe- 
tite and its value in nasal decongestants or 
cough medicines is quite questionable. 

Some of your patients can accidentally 
get into medical trouble with this drug, 
others on purpose. Head shops are selling 
"poor man's cocaine" — Pseudocaine," 
"Coco Snow," "Real Caine" and "Rock 
Crystal" — composed of ephedrine, PPA 
and procaine. Recently it has been re- 
ported that PPA can cause such sym- 
pathomimetic effects as severe hyper- 
tension, hypertensive crises or even renal 
failure. Such hypertensive responses 
have been reported after single doses of 
PPA in previously normotensive sub- 
jects. Long term ingestion can produce 
headache, palpitations, dizziness, weight 
loss, dysphoria and agitation. Acute side 
effects, even with recommended dosage, 
can also include tremor, restlessness, 
agitation, increased motor activity and 
hallucinations. An acute response to 
overdose can mimic amphetamine-psy- 



chosis with agitation, delirium, halluci- 
nations, panic states and confusion. Of 
particular interest are recent reports that 
phenylpropanolamine can not only in- 
crease blood pressure when taken alone, 
but also when combined with beta-adren- 
ergic blockers, methyldopa or MAO in- 
hibitors. Even more recently a patient 
presented in hypertensive crisis from 
the use of PPA and indomethacin. Ap- 
parently indomethacin and other drugs 
which inhibit prostaglandin synthesis can 
reduce the prostaglandin synthesis and 
induce severe vasoconstriction and hy- 
pertension. 

Treatment of severe reactions to phen- 
ylpropanolamine include phentolamine 
(Regitine) for an acute hypertensive epi- 
sode and diazepam for the CNS effects in 
adults (in pediatric patients chlorpro- 
mazine may be preferred). 

Consider phenylpropanolamine tox- 
icity in (1) patients who become acutely 
hypertensive and previously were nor- 
motensive (2) patients with acute CNS 
stimulation including psychosis (3) pre- 
school children with sudden onset of 
tremors, anxiety, hypertension and hal- 
lucinations (4) high school or college stu- 
dents before exams (is now replacing 
"white cross," "black beauties" or 
"black Cadillacs" for this purpose) (5) 
some "hyperactive" children. 

Because this drug is so easily available, 
it would be well to record its use in your 
data base. 

Ronald B. Mack, M.D. 
Department of Pediatrics 
Bowman Gray School of Medicine 

of Wake Forest University 
Winston-Salem, N.C., and 
Chairman, Committee on Accidents 

and Poison Prevention 
North Carolina Chapter of the 

American Academy of Pediatrics 



July 1981, NCMJ 



489 




SUGGESTIONS FOR AUTHORS 

The North Carolina Medical Journal wel- 
comes the contribution of original articles — scien- 
tific, historic and editorial — provided that they have 
neither been published previously nor have they been 
simultaneously submitted for publication in other 
medical periodicals. Papers concerned with all as- 
pects of the practice of medicine in North Carolina are 
particularly solicited. 

In addition, in view of "The Copyright Revision Act 
of 1976," effective Jan. 1, 1979, letters of transmission 
to the editor should contain the following language: "In 
consideration of the North Carolina Medical Society's 
taking action in reviewing and editing my submission, 
the author(s) undersigned hereby transfers, assigns, or 
otherwise conveys all copyright ownership to the North 
Carolina Medical Society in the event that such work is 
published in the NORTH CAROLINA MEDICAL 
JOURNAL." We regret that transmittal letters not 
containing the foregoing language signed by "all" au- 
thors of the submission will necessitate delay in review 
of the manuscript. 

Manuscripts 

Two copies of the complete manuscript including 
legends, tables, references and glossy prints should be 
submitted. All copies should be typed on standard size 
paper, double-spaced with margins at least 3 cm; 
xerographic reproductions are preferred to carbon. A 
covering letter indicating the author responsible for 
correspondence and his address should accompany 
the manuscript. 

Titles and Authors' Names 

These should be provided on a separate page in 
duplicate giving the full title of the paper; a shorter title 
for the table of contents; the author(s) first name(s), 
initial(s) and academic degree(s); the name of the de- 
partment and institution where the work was done and 
the name and address of the author to whom requests 
for reprints should be directed. 

Abstracts 

On a separate sheet, a double-spaced abstract of not 
more than 150 words should be submitted in duplicate. 
This should be factual telling of what was done, what 
was observed and what was concluded. A separate 
summary should not be provided. 



Abbreviations and Symbols 

Usage recommended in STYLE MANUAL FOR 
BIOLOGICAL JOURNALS (3rd ed., 1972) should be 
followed insofar as possible. The first time an abbrevi- 
ation is used, it should be explained. Generic names 
should be employed for drugs; if the author wishes to 
identify an agent by trade name, it should be inserted 
parenthetically at the first use of the term. Units of 
measurement should generally be metric including 
height and weight. 

References 

References should be double-spaced and on a sepa- 
rate page(s) and should be numbered consecutively as 
they are cited in the text. The citations should conform 
to the style of the INDEX MEDICUS and the publi- 
cations of the American Medical Association. The 
inclusive pages should be given but the number and 
day or month of the cited issue should not be included. 
Author(s) surname and initials(s); title and subtitle of 
the paper; journal or book in which it appeared; vol- 
ume number, inclusive pagination and year for journal 
citation; title or book, editor if a collection, edition 
other than first, city, publisher, year and page of 
specific reference for books should be indicated. For 
example: 

L Villant GE, Sobowale NC, McArthur C: Some 
psychologic vulnerabilities of physicians. N 
Engl J Med 287:372-375, 1972. 

2. Fox RC: The Student-Physician: Introductory 
Studies in the Sociology of Medical Education. 
Edited by Merton RK. Cambridge, Harvard 
University Press, 1957, pp. 207-241. 

3. Sniscak M: Cumulative Cumulus Therapy. Los 
Angeles, Exotic and Esoteric Press, 1984, p 81. 

Unpublished data and personal communications 
should be alluded to in footnotes. Footnotes, how- 
ever, should be limited and separated from the text by 
a line. 

Tables and Illustrations 

These should be typed in double-space on separate 
sheets. Arabic numerals should be used and a legend 
for each table submitted. Tables should be as succinct 
as possible. Lines should be omitted and symbols for 
units given with the column heading. Other symbols 
should be explained at the bottom of the table. Illus- 



490 



Vol. 42, No. 7 





W0 



For the ppn ^osteoarthritis 
the proven power of 

Motrin 

ibuprofen, Upjohn 

600 mg Tablets 

One tablet t.i.d. 

Please see the following page for a brief summarv' of prescribing information. 



l^john 



the Upjohn Ccx^pan\ • KaioTiazoo Michigan 49001 USA 



Motrin'' Tablets (ibuprofen. Upjohn) 

Contraindications: Individuals hypersensitive to it. or witti the syndrome of nasal 
polyps, angioedema. and bronchospastic reactivity to aspirin, iodides, or other non- 
steroidal anti-inflammatory agents. Anaphylactoid reactions have occurred in such 
patients 

Warnings: Peptic ulceration and gastrointestinal bleeding, sometimes severe, have 
been reported Ulceration, perforation, and bleeding may end fatally. An association has 
not been established Motrin should be given under close supervision to patients with a 
history of upper gastrointestinal tract disease, only after consulting ADVERSE REAC- 
TIONS 

In patients vifith active peptic ulcer and active rheumatoid arthritis, nonulcerogenic 
drugs, such as gold, should be tried If Motrin must be given, the patient should be under 
close supervision for signs of ulcer perforation or gastrointestinal bleeding 

Chronic studies in rats and monkeys have shovun mild renal toxicity characterized by 
papillary edema and necrosis Renal papillary necrosis has rarely been shown in 
humans treated with Motrin 

Precautions: Blurred and/or diminisiied vision, scotomata. and/or changes in color 
vision have been reported If these develop, discontinue Motrin and the patient should 
have an ophthalmologic examination, including central visual fields and color vision 
testing. Fluid relenllon and edema have been associated with Motrin: use with caution in 
patients with a history of cardiac decompensation or hypertension, Motrin is excreted 
mainly by the kidneys. In patients with renal impairment, reduced dosage may be nec- 
essary. Prospective studies of Motrin safety in patients with chronic renal failure have 
not been done Motrin can inhibit platelet aggregation and prolong bleeding time Use 
with caution in persons with intrinsic coagulation delects and those on anticoagulant 
therapy Patients should report signs or symptoms of gaslroinleslinal ulceration or 
bleeding, blurred vision or other eye symptoms, skin rash, weight gam, or edema To 
avoid exacerbation of disease or adrenal insufficiency, patients on prolonged cortico- 
sleroid therapy should have therapy tapered slowly when Motrin is added. The anti- 
pyretic, anti-inflammatory activity of Motrin may mask inflammation and fever. 
Drug interactions. Aspirin: used concomitantly may decrease Motrin blood levels. 
Coumarm; bleeding has been reported in patients taking /Mo//"//7 and coumarin 
Pregnancy and nursing mothers: Motrin should not be taken during pregnancy nor by 
nursing mothers. 
Adverse Reactions 

The most frequent type of adverse reaction occurring with Motrin is gastrointestinal, of 
which one or more occurred in 4°o to 16% of the patients 

Incidence Greater Thai] 1% (but less than 3%) -Probable Causal Relationship 
Gastrointestinal: Nausea:'" epigastric pain~ heartburn" diarrhea, abdominal distress, 
nausea and vomiting, indigestion, constipation, abdominal cramps or pain, fullness of Gl 
tract (bloating and flatulence): Central Nervous System: Dizziness:' headache, nervous- 
ness; Dermalologic: Rash' (including maculopapular type), pruritus. Special Senses: Tin- 
nitus: Metabolic/Endocrine: Decreased appetite: Cardiovascular: Edema, fluid retention 
(generally responds promptly to drug discontinuation, see PRECAUTIONS), 
Incidence Less Than 1%-Probable Causal Relationship" 

Gastrointestinal: Gastric or duodenal ulcer with bleeding and/or perforation, gastroin- 
testinal hemorrhage, melena. gastritis, hepatitis, jaundice, abnormal liver function tests. 
Central Nervous System: Depression, insomnia, confusion, emotional lability, somnolence, 
aseptic meningitis with fever and coma: Dermalologic: Vesiculobullous eruptions, urti- 
caria, erythema multiforme. Stevens-Johnson syndrome, alopecia: Special Senses: 
Hearing loss, amblyopia (blurred and/or diminished vision, scotomata. and/or changes 
in color vision) (see PRECAUTIONS); Hematologic: Neutropenia, agranulocytosis, aplastic 
anemia, hemolytic anemia (sometimes Coombs' positive), thrombocytopenia with or 
without purpura, eosinophilia. decreases in hemoglobin and hematocrit; Cardiovascular: 
Congestive heart failure in patients with marginal cardiac function, elevated blood 
pressure, palpitations. Allergic: Syndrome of abdominal pain, fever, chills, nausea and 
vomiting, anaphylaxis, bronchospasm (see CONTRAINDICATIONS), Renal: Acute renal 
failure in patients with preexisting, significantly impaired renal function, decreased 
creatinine clearance, polyuria, azotemia, cystitis, hematuria. Miscellaneous: Dry eyes 
and mouth, gingival ulcer, rhinitis 

Incidence Less Than 1%~Causal Relationship Unknown" 
Gaslroinleslinal: Pancreatitis. Central Nervous System: Paresthesias, hallucinations, 
dream abnormalities, pseudotumor cerebri; Dermalologic: Toxic epidermal necrolysis, 
photoallergic skin reactions; Special Senses: Conjunctivitis, diplopia, optic neuritis; 
Hematologic: Bleeding episodes (eg,, epistaxis, monorrhagia); Metaholic/ Endocrine: Gyne- 
comastia, hypoglycemic reaction; Cardiovascular: Arrhythmia (sinus tachycardia, sinus 
bradycardia). Allergic: Serum sickness, lupus erythematosus syndrome. Henoch- 
Schbnlein vasculitis; Renal: Renal papillary necrosis 

''Reactions occurring in 3% to 9% of patients treated with Motrin (Those reactions 
occurring in less than 3% of the patients are unmarked ) 

'Reactions are classified under "Probable Causal Relationship" (PCR) if there has been 
one positive rechallenge or if three or more cases occur which might be causally related 
Reactions are classified under "Causal Relationship Unknown" if seven or more events 
have been reported but the criteria for PCR have not been met 
Overdosage: In cases of acute overdosage, the stomach should be emptied. The drug 
IS acidic and excreted in the urine, so alkaline diuresis may be beneficial 

Dosage and Administration: Do not exceed 2400 mg per day. It gastrointestinal 
complaints occur, administer with meals or milk 

Rheumatoid arthritis and osteoarthritis, including flares of chronic disease; Sug- 
gested dosage is 300. 400. or 600 mg t id or q id Mild to moderate pain; 400 mg every 
4 to 6 hours as necessary for relief of pain 

Caution: Federal law prohibits dispensing without prescription 

lvlEDB-5-S 



Upjohn 







THE UPJOHN COMPANY 
Kalamazoo, Michigan 49001 USA 



July 1981 



rijl A Public Service of This Magazine 
Could 6t The Advertising Council 



FOREST FIRE PREVENTION CAMPAIGN 

MAGAZINE AD NO. FFP-1 1 97-81 

2V4" X 10" [110 Screen] CP-2-81/CM-3-81 



trations should be glossy, black and white prints or 
line drawings. The name of the first author, the figure 
number and the top of the figure should be written 
lightly in pencil on the back of each print. Legends are 
to be typed consecutively for each figure on a separate 
sheet. If illustrations have appeared elsewhere, per- 
mission for reproduction from both the author and 
publisher must accompany the manuscript. 

Reviewing 

All manuscripts are read by the editor. Most of them 
are also reviewed by members of the editorial board or 
other referees. Constructive comments by these re- 
viewers will be returned to authors who will usually be 
notified within one month of receipt of the manuscript 
of editorial action. Editorial correspondence should 
be directed to: 

Editor 

North Carolina Medical Journal 

300 S. Hawthorne Road 

Winston-Salem, North Carolina 27103 



WHY PHYSICIAN'S ASSISTANTS? 

The article by Reedy, Stewart and Quick reprinted 
in this issue of the North Carolina Medical Jour- 
nal describing the experience of Mr. Quick, a 
second-year physician's associate (PA) student at 
Duke Medical Center during his preceptorship in a 
family practice in England, provokes these thoughts 
about physician's assistants, physicians and the needs 
of patients. 

The physician's assistant concept is now over 15 
years old. Its roots belong firmly in North Carolina. 
Bom out of the vision of one man. Dr. Eugene Stead of 
Duke University, the program received early support 
from the North Carolina Medical Society which 
played an instrumental role in helping to define the 
evolving relationship between the physician and this 
new health profession. This has become a collabora- 
tive one in which the physician assumes medical and 
legal supervisory responsibility for the care provided 
by the PA. The North Carolina laws and regulations 
defining this association have become models for 
other states as their physicians began to employ 
physician's assistants. At every organizational level, 
physician's assistants have reaffirmed their support 
for the principle that the physician's assistant's role is 
a dependent one vis-a-vis the physician and that inde- 
pendent licensure for the physician's assistant does 
not serve the best interests of patients or physician's 
assistants. 

With the experience of the last 15 years and as a 
result of numerous studies including the one reprinted 



in this issue of the Journal, it is clear that the education 
of physician's assistants prepares them to effectively 
provide quality health care for commonly occurring 
medical and surgical problems.'"'' Studies also show 
that physician's assistants are well accepted by their 
patients and the physicians who employ them,''-^ and 
that they are productive and cost effective when 
utilized properly."" The recent Graduate Medical 
Education and National Advisory Committee 
(GMENAC) report recognizes these findings and rec- 
ommends that training of physician's assistants be 
maintained at current levels despite projected physi- 
cian surpluses. 

Originally, the PA concept was implemented in 
order to ease health manpower shortages in rural pri- 
mary care. We have since seen that physician's assis- 
tants can help to bring needed care to people in many 
more medical settings. Thus, PAs are working in 
nursing homes, in subspecialty practices, in prison 
health care systems and in emergency rooms. Because 
of the decline in the number of foreign medical gradu- 
ates entering this country, a new role has emerged — 
community hospitals and their physicians are turning 
to physician's assistants to provide continuous cover- 
age of inpatients and to facilitate coordination be- 
tween attending physicians and the hospital services 
provided to their patients. 

It is still early in the history of this profession so it 
cannot be predicted with sureness how it will ulti- 
mately develop. Yet, in 15 years, it has become clear 
that a physician working with a physician's assistant 
can increase the productivity of practice and also 
maintain or increase the quality and number of ser- 
vices provided. When medicine is being asked to pro- 
vide quality health care services at a reasonable cost 
to the consumer, it makes a great deal of sense that 
physicians should regard PAs as valuable and efficient 
members of the health care team. 

Michael A. Hamilton, M.D., M.P.H. 

Director, Physician's Associate Program 

Duke University Medical Center 

Durham, N.C. 27710 



References 



1. Sox HC Jr: Quality to patient care by nurse practitioners and physician's assistant: a 
ten-year perspective. Ann Intern Med 91:459-468. 1979. 

2. Record J. O'Bannon J. Blomquist R. Berger B: Evolution of a PA Program in the 
Oregon Kaiser-Permanente System: Policies. Practice Patterns and Quality of Care. 
Supported in part by HMEIA Contract N01-MB-44173(P). Presented to Fourth 
Annual Conference on New Health Practitioners. 1976. 

3- Kane R, Olsen D. Castle C; Medex and their physician preceptors. JAMA 236:2509- 
2512. 1976. 

4. Nelson E. Jacobs A. Johnson K: Patients' acceptance of physician's assistants. 
JAMA 228:63-67. 1974. 

5. Yanni F. Blackman P. Potash J; Physician attitudes on the physician's assistant. 
Physician's Associate 2:6-10. 1972. 

6. Nelson E. Jacobs A. Cordner K. Johnson K: Financial impact of physician assistants 
on medical practice. N Engl J Med 293:527-530. 1975. 

7. Record J. O'Bannon J: Cost Effectiveness of Physician's Assistants. Final Report. 
Prepared under Contract HMEIA NOl-MB-44173(P). Phase I. DHEW. Health Re- 
sources Administration. Bureau of Health Resources Development and Kaiser Foun- 
dation Health Services Research Center. Portland, Oregon. Apnl 1976. Phase II of this 
Contract: Cost Effectiveness of Physician's Assistants in a Maximum-Substitution 
Model. 



July 1981. NCMJ 



493 





did \JO\A V^tM\ 



By: Karen A. Zupko 

Director, AMA 

Department of Practice Management 



Do you want your telephone to ring off the hook? 
Do you want more money in accounts receivable 
than you have in the bank? How about running at 
least two hours behind schedule every Monday? 

We know three phrases that are guaranteed to 
produce these nightmarish results. They are; 

"Just give me a call and let me know how you 
feel.'' 
"Don't worry about the bill." 
"Come in and see me on Monday." 

Chances are these three phrases are familiarto you 
— maybe you've even used them. But perhaps you 
didn't realize the kind of trouble that these phrases 
can cause in your office. "What kind of trouble?" 
you ask. Well, let's take a look at the difference 
between what was meant, what was said, and what 
effect the comments listed above had on patients 
and your office. 

One physician we talked with said that when he 
started practice, he'd close each exam by saying, 
"Just give me a call and let me know how you feel." 
And most patients did just that. "Well," he recalls, 
"that was fine when I was starting out and only 
seeing about 10 patients a day. But as my practice 
grew so did the number of patient callers. It got to 
the point where I was making nearly 25 callbacks a 
day, only to hear that the medicine or treatment 
regimen was working just fine." In his case, his 
nurse finally noticed the pattern and called it to his 
attention. Happily, he's reformed and has found 
other ways to end a patient's visit and leave the 
exam room. He's also implemented better tele- 
phone protocols and screening techniques at the 
reception desk. 

The result is that needless callbacks have been 
reduced. Substitute phrases that he now uses to 
close an exam include: "If you still have pain in two 



494 



days, call me, " or 'If you don't feel better in a week, 
call and make another appointment. " In both ex- 
amples, the patient instruction is more specific. 

"Don't worry about the bill, " isanotherluluand it 
usually works like this. You've just seen Patty Pa- 
tient and she looks up at you and says, "Ah, this 
treatment will probably mean a big bill and frankly 
. . ." Before Ms. Patient can finish you ease toward 
the exam room door and say, "Don't worry about 
the bill — just get well," as you escape into the hall. 

You should realize that this is an instruction 
most patients will follow to the letter — in fact it 
may be the only instruction they follow. And it is 
this phrase that will ring in your ears as you look 
over your growing accounts receivable. Not only 
has f^s. Patient not worried about the bill, she 
hasn't even begun to pay it. If discussing money 
with patients makes you uneasy, and it shouldn't by 
the way, have your staff help you. For instance, 
instead of "Don't worry about the bill," why not try, 
"Please see Betty Bookkeeper, she'll make ar- 
rangements for you," or something like that. 

If you really and truly don't want Ms. Patient to 
worry about paying you and you stand ready to 
forgive the amount due be sure you communicate 
this to your staff. Unaware of the arrangement 
you've made with Ms. Patient, they may be sending 
out dunning letters or asking for payment at the 
front desk, all which make Ms. Patient feel like 
you've gone back on your word. 

Now let's look at the last phrase. A friend of mine 
tells me that whenever he wants a "squeeze-me-in" 
appointment with his physician, he calls him at 
home on Sunday. "Without fail," he smiles, "the 
doctor says for me to come in and see him on 
Monday." And, he points out that the doctor is a 
soft touch compared to the medical assistant in his 
office. 

Watch out for patients like my friend. Many times 
patients like him truly aren't feeling well, and while 
they don't need an emergency room visit, a pre- 
scription, or a house call they do want and/or need 

Vol. 42. No. 7 



something from you. The key question to ask your- 
self is: "Do they need an appointment on Mon- 
day?" Often times patients like my friend, have 
simply neglected to follow the routine of calling to 
set aside some time for a visit for their non-urgent 
problem. And do consider the results. . . 

A crowd gathers on Monday morning in your 
exam room that is so large it rivals 5th Avenue on 
the day of the Easter parade. Then, the following 
scenario is played. 

A patient stands at the reception desk and your 
medical assistant scans the appointment book and 
says, "Ah, but I don't have an appointment for 
you." The patients who did call ahead and who do 
have appointments are now glaring. The patient at 
the reception desk, well he or she rises to their full 
dignity and replies: "But, the doctor told me. . . ." 
The receptionist is now effectively undermined and 



you — well you are going to be running behind all 
day. 

The solution? Try what an established Illinois 
physician with a busy practice does. He tells pa- 
tients, "Please be sure to call my office first thing 
on Monday and tell the medical assistant that I 
want to see you." And, don't stop there. To further 
prevent a case of the crazy Mondays, be sure that 
your office staff leaves a certain number of ap- 
pointments open for these call-ins. It's a bit of pre- 
ventive medicine that will cut waiting time for pa- 
tients, keep you and your staff sane and on sched- 
ule and that will accommodate the patient who 
does need to be seen. 

Hopefully, these new ideas will result in im- 
provements in your practice communications. If 
they don't you can either give me a call or come in 
and see me on Monday at AMA — and don't worry 
about the bill; this advice is free. 



July 1981. NCMJ 



495 




PHARMACY AND MEDICINE 

To the Editor: 

The historical natural alliance of pharmacy and 
medicine is certainly important: there is very little in 
Stephen W. Shearer's editorial in the January North 
Carolina Medical Journal with which one could 
disagree. 

I am personally concerned about the growing trend 
in training programs to delegate to non-physician per- 
sonnel areas of responsibility and knowledge formally 
reserved for physicians. I feel that this approach may 
ultimately lead to increased fragmentation of medical 
care and further depersonalization of the doctor- 
patient relationship. At a time when our national goals 
are oriented toward primary care and getting one's 
medical treatment from one source, this trend appears 
counterproductive. 

I fail to see how increasing the complexity of the 
present health care delivery system could result in a 
decrease in medical costs. I feel that utilizing the ser- 
vices of a clinical pharmacist as a consultant would 
depend on data that would support a cost effective 
approach. 1 doubt if the use of drugs recommended by 
a clinical pharmacist would result in any less risk of 
iatrogenic disease related to adverse drug reactions, 
since I feel that the use of drugs in any patient popula- 
tion will always result in a certain percentage of ad- 
verse reactions. I do not feel that we should depend on 
a consultation with the clinical pharmacist to decide if 
drug treatment should be initiated. I believe that this is 
an area in which the physician should retain the 
knowledge and skill to determine therapy. 1 feel that 
the expansion of clinical pharmacy programs should 
be determined by whether their presence in a situation 
with well trained physicians creates any decreased 
cost of medical care. 

William W. Fore, M.D., Greenville, N.C. 

Immediate Past President 

North Carolina Society of Internal Medicine 

To The Editor: 

I would like to thank Dr. Fore for commenting on 
my editorial in the January North Carolina Medi- 
cal Journal. I agree that increased depersonaliza- 
tion and fragmentation of medical care may not be in 
our best interests. These are concerns that should be 
addressed in developing all new health professional 
roles. In my practice, I work with the patient's pri- 
mary physician providing information about the 



problem at hand, avoiding fragmentation and deper- 
sonalization. 

Dr. Fore has asked for data about the cost effective- 
ness of a clinical pharmacy practice. I cite several 
articles: 

Massoud and Gudougkas evaluated a clinical phar- 
macy service in a 170-bed community hospital and 
found that a 409?^ reduction in medication orders could 
have been achieved if the recommendations of the 
clinical pharmacist had been followed.' Second, 
Knapp et al found that inappropriate drug prescribing, 
as defined by explicit screening criteria, increased the 
length of hospital stay by 1.8 days.- Next, McKenney 
and Wasserman reported that adverse drug reactions 
decreased from 20% of 77 patients to 15.6% of 64 
patients and, finally, to 8.2% of 73 patients (p < 0.05 
for the first and third reaction rates). ^ The comparison 
was between a traditional floor stock drug distribution 
system without a pharmacist, a floor stock system 
with pharmacist and a unit dose system with a phar- 
macist. Pathak and Nold observed that with physician 
approval patient training for home administration of 
antihemophilic factor, calcitonin, cytarabine, injecta- 
ble analgesics and parenteral nutrients by pharmacists 
saved $833,723 over two years. They noted that for 
every dollar charged by the pharmacy service 1.25 
days of hospitalization and $32 1 .90 in hospital charges 
were saved. ^ Sohn et al'^ found that by educational 
programming, including personal contact with the 
clinical pharmacy staff, the cephalosporin budget of 
the medical center involved could be reduced by 
$56,413.44. 

In a large teaching hospital, Elenbaas, Payne and 
Bauman*^ showed that having a clinical pharmacist 
consult with the patient's physician before requesting 
measurement of drug blood level saved the hospital 
$12,086.61 annually. 

Covinsky, Hamberger and Twin studied the impact 
of the docent clinical pharmacist," who functions with 
a physician (docent team leader), nurse, clinical medi- 
cal librarian, dietician and social worker and found 
that for treatment of pneumococcal pneumonia the 
length of stay and total antibiotic cost were 13% and 
80% lower respectively than a control site. The au- 
thors projected an annual savings of $50,000 in drug 
costs in long term care. In ambulatory care, the effect 
of these services has been to decrease the average 
medication cost per patient visit from $9.00 in 1971 to 
$4.00 in 1980. 



496 



Vol. 42. No. 7 



Kelly and his colleagues* found that consultations 
by a clinical pharmacist could reduce intravenous 
therapy cost from $23,518 to $9,174 annually. 

An important point about all of these studies is that 
the clinical pharmacist provides services in associa- 
tion with the patient's physician. 

Dr. Fore exhibits a healthy skepticism about ac- 
cepting the role of a clinical pharmacist before he has 
had the opportunity to first examine it. He may be 
interested in discussing the role and usefulness of 
a clinical pharmacist with other North Carolina in- 
ternists who have had the opportunity to use their 
services. In this manner, the role of the chnical phar- 
macist can be better defined. However, clinical phar- 
macists should be evaluated individually as to their 
capability to perform this role. 

Stephen W. Shearer, M.S., Tarboro, N.C. 

References 

1 . Massoud N . Gudouskas: The utilization of a clinical pharmacist — a way of decreasing 
medication in a community hospital. Drug Intel Clin Phann 13:266-271. 1979. 

2. Knapp DE. Knapp DA. Speedie MK. et al: Relationship of inappropnate dnjg pre- 
scribing to increased length of hospital stay. Am J Hosp Pharm 36:1334-1337, 1979. 

3. McKenney JM. Wassennan AJ: Effects of advanced pharmaceutical services on the 
incidence of adverse drug reactions. Am J Hosp Pharm 36:1691-1697. 1979. 

4. Pathak DS. Nold EG: Cost-effectiveness of clinical pharmaceutical services: a 
follow-up report. Am J Hosp Pharm 36:1527-1529. 1979. 

5. Sohn CA. Wolter HA. McSweeney GW: Effectiveness of a cephalosporin education 
program — a pharmacy education program. Drug Intel Clin Pharm 14:272-277, 1980. 

6. Elenbaas RM. Payne VW, Bauman JL: Influence of clinical pharmacist consultations 
on the use of drug blood level tests. Am J Hosp Pharm 37:61-64, 1980. 

7. Covinsky JO. Hamberger S. Twin EJ: A look at the educational responsibilities and 
cost impact ofthedocent clinical pharmacist. Drug Intel Clin Pharm 14:266-271. 1980. 

8. Kelly KL, Covinsky JO. Fendler K, Bauman JL: The impact of clinical pharmacy 
activities on intravenous fluid and medication administration. Drug Intel Clin Pharm 
14:516-520. 1980. 



To the Editor: 

While I appreciate Mr. Shearer's review of recent 
pharmacy literature on the use of clinical pharmacists 
in hospital practice, I still am not convinced that wide- 
spread usage of these specialists would lower overall 
medical costs. The studies cited by Shearer were lim- 
ited in scope and failed to take into account the cost to 
the hospital (and inevitably, to the patient) of the 
clinical pharmacist's salary plus the cost to the health 
care system of training the clinical pharmacist. Also, 
time spent in consultation with the clinical pharmacist 
would be time lost from patient care. 

I feel that he has drawn unwarranted conclusions 
from the studies cited, including the one by Mc- 
Kenney and Wasserman in which the authors them- 
selves stated that the study "suggests although does 
not prove" that the pharmacy services described in 
the study might achieve an overall decrease in the 
incidence of adverse drug reactions and a corre- 
sponding decrease in the length of hospital stay. I also 
noted upon reviewing the study by Massoud and 
Gudougkas that "of the 215 therapeutic comments 
presented by the pharmacy resident, only 38 were 
actually followed through by the attending physician" 
and "the reviewing physicians disagreed with 37 of the 
total comments made by the pharmacy resident." 

I would like for you to understand that I agree fully 
with the role and usefulness of the clinical pharmacist 
in the training of physicians but I remain unconvinced 
that the use of the clinical pharmacist in a private 
practice setting is cost effective. 

William W. Fore, M.D. 



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July 1981. NCMJ 



497 




NEW MEMBERS 

of the State Society 



ALAMANCE-CASWELL 

Harviel. Jay Duncan, (OS) 719 Hermitage Road, Burlington 27215 
Johnson. Leslie Donald. (R) 733-G Colony Apartments, Burlington 
27215 

BEAUFORT-HYDE-MARTIN-WASfflNGTON-TYRRELL 

Alligood. Toby Ray. (D) 2 E Stirrup Court. Cocketsville, Maryland 
21070 

BUNCOMBE 

Bailey, John Bennett. 77 McDowell Street, Asheville 28801 




Two convenient dosage 
forms; 100 mg (white) and 
C/ifP-y^ 300 tng (peach) Scored 
Tablets 



Tablets imprinted with 
brand name to assist in 
S^'^^J tablet identification. 



i^^ / Burroughs Wellcome Co. 
'^y^ / Research Triangle Park 
WoHcomf/ North Carolina 27709 



CATAWBA 

Blair, William Shelton. (AN) 926 Second Street. N.E.. Hickory 

28601 
Deperezel. John Leslie. (ORS) 521 1 1th Ave. Circle NW. Hickory 

28601 

CRAVEN-PAMLICO-JONES 

Schnee. Charles Frederick, (GS) 290 Shoreline Drive. New Bern 

28560 
Scovil. James S. Jr.. (CD) P.O. Box 2605. New Bern 28560 

DURHAM-ORANGE 

Bennett. Craig Randall. (STUDENT) 233-C Jackson Circle. Chapel 

Hill 27514 
Bunge. Robert John. (RESIDENT) 1213 Carolina Street, Durham 

27705 
Cohen, Philip Lawrence, (IM) University of N.C.. 932 Flob231H. 

Chapel Hill 27514 
Erickson. Lars Carl. (STUDENT) Box 2815. Duke Medical Center, 

Durham 27710 
Grote. Thomas Howard. (STUDENT) Route 1 , Box 378A, Durham 

27705 
Hindsley. John Pack. Jr., (U) UNC, Division of Urology, 428 

Burnett-Womack BIdg., Chapel Hill 27514 
Osbahr. Albert James. (STUDENT) 407 Northampton Apartments. 

Chapel Hill 27514 
Rawlings, Charles Edward, III, (STUDENT) 1500 Duke Univ. 

Road. Apt. F2C. Durham 27705 
Roberts. Kenneth Berwick, (STUDENT) 1700 W. Markham Av- 
enue. Durham 27705 
Saunders, Timothy Gray, (STUDENT) 57 Laurel Ridge Apts.. 

Chapel Hill 27514 
Strope. Gerald Leiand. (PD) 1 14 Collums Road. Chapel Hill 27514 
Swift. Ronnie Gorman. (P) Route 7. Box 284. Chapel Hill 27514 

FORSYTH-STOKES-DAVIE 

Bryson, Gary Keith. (RESIDENT) 6105 Lottie Lane, Chattanooga. 
TN 37416 

Formanek. Augustin Gustav. (R) 103 Helleri Court. Box 617. Ad- 
vance 27006 

GUILFORD 

Brooks. Donald Frederick, (RESIDENT) 231 1-F N. Church Street, 
Greensboro 27401 

HERTFORD 

Daughtridge, Truman Giffin, (R) P.O. Box 459. Ahoskie 27910 

IREDELL 

Cherry. William Hill Jr.. (OBG) 323 Auguste Drive. Statesville 
28677 

LEE 

Lamberts. Eric William, (GP) Route 1, Box 521, Lillington 27546 

MECKLENBURG 

Reindoller. Robert William. (IM) 3155 Harwick Place, Charlotte 

28211 
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ONSLOW 

Patel. Kanchanlal Shankerbha. (GP) 603 Doris Avenue. Jackson- 
ville 28540 

PITT 

Burtner. David Emerson. (FP) P.O. Box 136. Dept. of Family 
Practice. Greenville 27834 



498 



Vol. 42, No. 7 



I Clark, Jeffrey Brothers, (STUDENT) 915 College View Apts., 
I Greenville 27834 

Stein, Charles Alan, (RESIDENT) Route 8, Box 330-7, Greenville 
27834 

Trent, Lee Royal III, (FP) Route 4, Box 534, Tarboro 27886 

ROCKINGHAM 

Moore, Donald Wilson, (FP) Route 4, Box 854-A, Tern Lane, 
Madison 27025 

RUTHERFORD 

Sheets, Douglas Dean, (OBG) 22 Ivey Drive, Rutherfordton 28139 

UNION 

Nelson, Richard Allan, (PD) Box 337, Wingate 28174 

WAKE 

Kiley, James William, (OPH) 3410 Executive Drive, Raleigh 27609 
Shah, Nirurama Bipin, (IM) 912 Tate Drive, Raleigh 27603 



WHAT? WHEN? WHERE? 

In Continuing Education 



July 10-12 

31st Annual Institute on Tuberculosis & Other Respiratory Dis- 
eases 

Place; YMCA — Blue Ridge Assembly, Black Mountain 

Fee: $30 

For Information: C. Scott Venable, Executive Director, American 
Lung Association of N.C., P.O. Box 27985, Raleigh 27611 or 
(919) 832-8326. 

July 13-17 

23rd Annual Postgraduate Course (Morehead Symposium) 
Place: Bogue Banks Country Club, Atlantic Beach 
Fee: $235 

Credit: 30 hrs, AAFP applied for 

For Information: Harry A. Gallis, M.D., Box 3306, Duke Univer- 
sity Medical Center, Durham (919) 684-3279 



July 16-18 

3rd Annual Mountain Meeting 
Place: Grove Park Inn, Asheville 
Credit: 12 hrs 
Fee: $100 

For Information: Emery C. Miller, M.D., Dept. of Cont. 
Bowman Gray School of Medicine, Winston-Salem 



Ed. 



Please note: I. The Continuing Medical Education Programs at 
Bowman Gray, Duke, East Carolina and UNC Schools of Medi- 
cine, Dorothea Dix, and Burroughs Wellcome Company are ac- 
credited by the American Medical Association. Therefore CME 
programs sponsored or cosponsored by these schools automatically 
qualify for AMA Category I credit toward the AMA's Physician 
Recognition Award, and for North Carolina Medical Society Cate- 
gory A credit. Where AAFP credit has been requested or obtained, 
this also is indicated. 

2. The "place" and "sponsor" are indicated for a program only 
when these differ from the place and source to write "for informa- 
tion." 



July 27-August 1 

Radiology Postgraduate Course 
Place: Bogue Banks Country Club, Atlantic Beach 
Fee; $250 

Credit; 30 hrs, AAFP applied for 

For Information: Donald Kirks, M.D., Box 3308, Duke Med. 
Durham 27710 



Ctr., 



July 31-August 1 

Symposium on Cardio-Vascular Diseases 

Place: Holiday Inn, Wrightsville Beach 

Information: Emile E. Werk, Jr., M.D.. Chief of Medicine, Univer- 
sity Medical Service, Area Health Education Center, 2131 South 
I7th St., Wilmington, N.C. 28401. 



IF YOUR PATIENT TELLS US 
SHE'S PREGNANT, 

SHE WON'T GET A LECTURE. 
SHE'LL GET HELP. 

Free, professional problem pregnancy counseling. 
If she can't come to us, we'll come to her. ^-^a 

The Children's Home Society of North Carolina, Inc. 



Asheville (704) 258-1661 Favetteville (919) 483-8913 

Chapel Hill (919) 929-4708 Greensboro (919) 274-1538 

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Wilmington (919) 799-0655 



Member Child Welfare League of America. Founded 1902. 



July 1981, NCMJ 



499 



September 15 

5th Annual Cape Fear Medical Symposium 

"Update in Infectious Diseases" 

Place: Bordeaux Motor Inn, Fayetteville 

Credit: 7 hours 

For Information: Mrs. Mary Henley. Fayetteville Area Health 

Education Center. P.O. Box 64699. Fayetteville 28^06 or 919/ 

323-1152 

The items listed in the above column are for the six months 
immediately followingthe month of publication. Requests for listing 
should be received by "WHAT? WHEN? WHERE?". P.O. Box 
27167. Raleigh 276 II. by the 10th of the month prior to the month in 
which they are to appear. A "Request for Listing" form is available 
on request. 



News Notes from the — 

DUKE UNIVERSITY MEDICAL CENTER 



Dr. David G. Shand is the winner of the 1981 
ASPET award, given by the American Society for 
Pharmacology and Experimental Therapeutics to a 
researcher whose work helps bring research and 
therapy closer together. Shand's work is centered 
around research on a group of drugs used to treat chest 
pain and inegular heart rhythms; he is also studying 
the effects of individual biochemical differences on 
the efficacy of therapeutic drugs. 

Shand, professor of pharmacology and chief of the 
division ofclinical pharmacology, was a 1 980 recipient 
of one of two clinical pharmacology awards from the 
Burroughs Wellcome Fund. A holder of M.B. and 
Ph.D. degrees from St. Bartholomew's Hospital 
Medical College. London, Shand came to Duke in 
1978 and established the division of clinical phar- 
macology that same year. 



The Fifteenth Annual Symposium on Environ- 
mental Effects on Brain Development was held at the 
medical center on April 27. Topics of the scientific 
sessions included ways in which drugs affect the 
brain's development and functioning; functional dif- 
ferences between the brains of men and women; and 
the effects of maternal deprivation on the growth and 
development of infant animals. 



Dr. H. Keith H. Brodie has been elected president 
of the 25,000-member American Psychiatric Associa- 
tion (APA), the largest psychiatric group in the nation 
and the nation's oldest medical society. 

Brodie is chairman of the Department of Psychiatry 
at Duke University Medical Center and is James B. 
Duke Professor of Psychiatry and Law. 

"These are interesting times for psychiatry," 
Brodie said. "The mental health care dollar will have 
to be defended in Congress. Training funds for psy- 
chiatrists are already deleted in the face of recent 
studies establishing the need for more psychiatrists. 
Another issue will be establishing reimbursement pro- 



500 



C/CIAPEH-W {cydoc^ 

Indications 

Cyclacillin hoi less in vitro activity than other drugs in the ampicillm 
clan and ili use shoold be confined (o these mdicoltons, Treotment 
of the (ollowing infections; 
RESPIRATORY TRACT 

Tonsillitis and phoryngitis caused by Group A beto-hemolylic 

streptococci 

Bronchitis and pneumonio caused by S . pnetimonioe (formerly 

D . pneumoniae) 

Otitis media caused by S pneumonioe (formerly D. 

pneufnonjoe) and H. inf/uenzoe 

Acute exacerbation of chronic bronchitis caused by H, in- 
fluenzae' 

'Though clinicot improvement has been shown, bocteriologic 

cures cannot be expected in all patients with chronic respi- 

rotory disease due to H. influenzae 
SKIN AND SKIN STRUCTURES (integumentary) infections caused 
by Group A beto-hemolytic streptococci and staphylococci, non- 
penicillinase producers. 

URINARY TRACT INFECTIONS caused by E. coli and P, mirobilis. 
(This drug should not be used in any f . coit and P. mirobilis infec- 
tions other than unnory tract.) 

NOTE: Perform cultures and susceptibility tests initially and dur- 
ing treatment to monitor effectiveness of therapy and susceptibil- 
ity of bacterio, Therapy may be instituted prior to results of sen- 
sitivity testing. 

Contraindications Contraindicoled in individuals with history of 
on allergic reaction to penicillins. 

Warnings Cyclacillin should only be prescribed for the indica- 
tions listed nerein. 

Cyclacillin has less in vitro activity thon other drugs of the 
ampicillin class. However, clinical trials den^onstrated it is ef- 
ficacious for recomnnended indications 

Serious and occasional fatal hypersensitivity (anophylactoid) 
reactions have been reportecl in patients on penicilltn Al- 
though anaphylaxis is more frequent following parenlerol 
use, it has occurred in patients on orat penicillins These reac- 
tions are more apt to occur in individuals with history of sen- 
sitivity to multiple allergens. There are reports of patients 
with history of penicillin hypersensitivity reactions who ex- 
perienced severe hypersensitivity reactions when treated 
with a cephalosporin. Before penicillin theropy, corefully in- 
quire about previous hypersensitivity reactions to penicillins, 
cephalosporins and otner allergens, (f allergic reaction oc- 
curs, discontinue drug and initiate appropriate theropy Seri- 
ous anaphylactoid reactions require immediate emergency 
treatment with epinephrine. Oxygen, I.V. steroids, airway 
management, including intubation, should also be adminis- 
tered OS indicated. 

Precautions Prolonged use of antibiotics may promote Over 
growth of nonsusceptible orgonisms. It superinfection occurs, take 
appropriate measures. 

PREGNANCY Pregnancy Cotegory B. Reproduction studies per- 
formed in mice and rats ot doses up to tO times the humon aose 
revealed no evidence of impaired fertility or harm to the fetus due 
to cyclacillin. There ore, however, no adequate ond well- 
controlled studies in pregnant women, Because onimol reproduc- 
tion studies ore not always predictive of humon response, use this 
drug during pregnancy only if clearly needed. 
NURSING MOTHERS: It is not known whether this drug is excreted 
in human milk. Because many drugs ore, exercise cou'ion when 
cyclacillin is given to o nursing woman. 

Adverse Reactions Oral cyclacillin is generally well tolerated As 
with other penicillins, untoward sensitivity reoctions are likely, 
particularly in those who previously demonstrated penicillin 
hypersensitivity or with history of ollergv, asthma, hay fever, or 
urticaria. Adverse reactions reported with cyclacillin: diarrhea (in 
approximately 1 out of 20 patients treoted), nausea ond vomiting 
(in opproximately 1 in 50), and skin rash (in opproximolely 1 m 
60} Isolated instonces of headache, dizziness, abdominal pom, 
vaginitis, and urticaria hove been reported. (See WARNINGS) 
Other less frequent adverse reoctions which may occur and are 
reported with other penicillins ore onemio, thrombocytopenia, 
thrombocytopenic purpura, leukopenio, neutropenia and 
eosinophilia These reactions ore usually reversible on discontinu- 
ation of therapy. 

As with other semisynthetic penicillins, SGOT elevations hove been 
reported 

As with antibiotic therapy generally, continue treotment ot least 
48 to 72 hours ofter potient becomes osymptomotic or until bacte- 
rial eradication is evidenced In Group A beto-hemolytic strep- 
tococcal infections, at least 10 doys' treatment is recommended to 
guard against risk of rheumotic fever or glomerulonephritis. In 
chronic urinary tract infection, frequent bocteriologic and clinical 
appraisal is necessary during therapy and possibly for several 
months after Persistent infection may require treatment for sev- 
eral weeks. 

Cyclacillin is not indicated in children under 2 months of age 
Pofienti with Renal failure Cyclacillin may be safely administered 
to patients with reduced renal function. Due to prolonged serum 
half-life, patients with various degrees of renal impairment may 
require change in dosoge level (see DOSAGE AND ADMINISTRA- 
TION in package insert). 
Dosage (Give in equally spaced doses) 



INFECTION 


ADULTS 




CHILDREN* 


Respiratory 
Trad 

Tonsillitis & 
Pharyngitis 


250 mgq. 


d. 


body weight < 20 kg 
(44 lbs) 125 mg q.i.d 


Bronchitis and 
Pneumonio 






body weight > 20 kg 

(44 lbs) 250 mg q.i.d 


Mild or 
Moderate 

Infections 


250 mg q. 


d. 


50 mg/kg/doy q.i d 


Chronic 
Infections 


500 mg q. 


d. 


100 mg/kg/doy q.i.d 



Otifrs Medio 250 mg to 500 mg 50 to 100 mg/kg/doyt 

q.i.d, t 
Slcin & Skin 250 mg to 500 mg 50 to 100 mg/kg/dayt 

Structures q.i.d. t 

Urinary Tract 500 mg q.i.d, 100 mg/kg/doy 

'Dosage should not result m o dose higher than that for adults, 
tdepending on severity 

Wyeth Laboratories 

I '' ■" "'^iiadeiphia.Pa 19101 



\AJ' 



Half the dose 
is absorbed in 9 minutes! 

compared to 32 minutes for ampicillin * 




Mean blood levels in mcg/ml after 250 mg 
cyclacillin single oral dose 




12 3 4 5 

Time (hours after administration) 



Rapid, virtually connplete absorption from Gl tract 
Exceptionally high peak blood levels — 3 times 
greater than ampicillin (Clinical efficacy may not 
always correlate v/ith blood levels.) 
Rapidly excreted unchanged in urine — 
V/2 times faster than ampicillin 



Fewer episodes of diarrhea and rash 
than with ampicillin in studies to date. 

Efficacy proven in the treatment 
of bronchitis, pneumonia, and upper 
respiratory infections J 

In 117 patients, 73 with bronchitis/pneumonia 
caused by S . pneumonioe and 44 with streptococcal 
sore throat caused by Group A beta-hemolytic 
streptococcus, CYCLAPEN--W achieved a clinical 
response rate of 100%! Bacterial eradication was 
95% and 86% respectively. 

"Doe to susceptible organisms. 

See important information on Facing page. 



[Based on T V2 values for single oral doses of 500 mg cyclacillin 
jtablet ond 500 mg ampicillin capsule. Data on file, Wyeth Laboratories, 

Copyright© 1980, Wyeth Laboratories. All rights reserved. 



veth Laboratories ■ pniadeiphia pa 19101 

'Mm 



CKCLIPEN-IV^ 

(I • 1 1 • \ 250 and 500 mg Tablets 

cyclacillin) -ts?--- a^ 

more than just spectrum >v^ 



cedures bringing mental health to parity with the rest 
of the care field." 

Brodie will serve as president-elect until May. 1982. 
He will assume the presidency of his association in the 
same month that William Bevan, provost of Duke 
University, becomes president of the American 
Psychological Association. 

Brodie came to Duke as chairman of psychiatry in 
1974, after serving as assistant professor of psychiatry 
and program director of the General Clinical Research 
Center at Stanford. He received his undergraduate 
degree in chemistry from Princeton University and his 
M.D. degree from Columbia University College of 
Physicians and Surgeons. 



The Duke Alzheimer's Family Support Network 
was incorporated in April at the regular monthly 
meetings of family, friends and professionals involved 
with victims of the incurable brain disorder that af- 
fects between 500,000 and 1 .5 million Americans. The 
Duke group is a chapter of the National Alzheimer's 
Disease and Related Disorders Association and at- 
tracts attendants from four states for the meetings. 



A biomedical researcher at Duke University Medi- 
cal Center is among the first 12 Searle Scholars to 
receive three-year, $150,000 grants for research sup- 
port. Dr. James E. Niedel, assistant professor of 
hematology and oncology in the Department of Medi- 



PULMONARY DIAGNOSTIC 
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TO COMPLETE PULMONARY 
FUNCTION STUDIES 



Arterial Blood 

Gases 
Spirometrv 
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I- PHYSICIAN SUP&rtVISED 



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^ 



cine, received the award for his application, "Human 
Leukocyte Chemotactic Receptor." 

Niedel is studing chemotaxis, the mechanism by 
which leukocytes, white blood cells, recognize signals 
of bacterial invasion and migrate to the site of the 
invasion and combat it. 

Niedel received his M.D. and Ph.D. degrees from 
the University of Miami and was an intern, resident 
and fellow at the medical center before joining the 
Duke faculty. 

He described the Searle Scholars Program as "wel- 
come, not just for me, but for the field of research, 
because it recognizes the need to encourage and sup- 
port researchers who are just beginning their 
careers." 

The Searle Scholars Program was established with 
a grant from the trustees of the Searle Family Trust. 
The trust was established under the will of John G. 
Searle, grandson of the founder of G. D. Searle& Co., 
a research-based pharmaceutical firm in Skokie. Il- 
linois. 

* * * 

Richard Frothingham and Robert Kinney, senior 
medical students, were recipients of MAP-RDl fel- 
lowships to do clinical work, in, respectively, Benin 
(formerly Dahomey) and Liberia. The awards were 
among 23 announced this spring by the Medical As- 
sistance Program and the Reader's Digest Interna- 
tional Fellowship of Wheaton, Illinois. Five Duke 
medical students have received M AP-RDI fellowships 
in the last two years. 

The annual Wiley Forbus Award of the North Caro- 
lina Society of Pathologists has gone to Dr. Kenneth J. 
Widder for his work in developing methods of target- 
ing anti-cancer drugs to specific sites of tumors. The 
Forbus award — named for Dr. Forbus, first professor 
and chairman of the Department of Pathology at Duke 
— is given each year to the pathology resident who 
makes "an outstanding contribution to the field of 
pathology." 

The award was based on a paper by Widder and 
others describing a promising technique of delivering 
drugs to tumors. The technique involves loading 
microspheres — artificial cells about one-eighth the 
size of red blood cells — with drugs and drawing them 
to the site of the tumor by holding magnets near the 
tumor. In this way, drugs can be targeted specifically 
to the tumor, leaving the surrounding healthy cells 
untouched. 

Widder received his M.D. degree from Northwest- 
ern University in 1979 and began his residency at 
Duke that same year. His co-researchers in the work 
were Dr. Andrew E. Senyei of the University of; 
California-Irvine and Drs. Robert M. Morris, Donald' 
Howard and Gerry Poore of Eli Lilly and Co., a maker 
of pharmaceuticals. 

Dr. Alfred R. Shands, Jr., nationally known or- 
thopaedist and first chief of the division of ortho-j 



502 



Vol. 42, No. 7, 



I paedics at Duke University School of Medicine, died 
April 20 at the age of 82. 
Shands was a member of the original faculty of the 

I medical school. During his years at Duke (1930-37) 

! Shands co-authored, with Dr. R. Beverly Raney, Jr., 
"A Handbook of Orthopaedic Surgery." which is still 
in print. Shands served as president of the American 

i Orthopaedic Association in 1953-54, and the associa- 
tion later established a lectureship in his honor, the 
only such lectureship of the organization. His father. 



Dr. A. R. Shands, was a charter member of the Ameri- 
can Orthopaedic Association and also served as its 
president. 

Shands left Duke in 1937 to become medical direc- 
tor of the Nemours Foundation of Wilmington, Dela- 
ware. He also served as surgeon-in-chief of the Alfred 
1. Du Pont Institute and visiting professor of or- 
thopaedic surgery at the University of Pennsylvania. 

He is survived by his wife, Elizabeth (Polly), a son, 
A. R. Shands, III, and a sister, Agnes Shands. 




July 1981. NCMJ 



503 



News Notes from the— 

BOWMAN GRAY SCHOOL 
OF MEDICINE 

WAKE FOREST UNIVERSITY 



New research at the Bowman Gray School of Medi- 
cine has established another link between hyperten- 
sion and a hormone which was discovered at the 
school last year. 

For the first time, scientists have shown in an ani- 
mal closely related to man that there is an association 
between the hormone, endoxin, and hypertension. 
And they have shown that levels of the hormone in the 
blood correspond to the extent of hypertension. 

Results of the latest Bowman Gray research on 
endoxin were reported to the annual meeting of the 



Federation of American Societies for Experimental 
Biology. 

The Bowman Gray researchers also have found that 
by monitoring the level of endoxin in the blood, it may 
be possible to predict the eventual onset of certain 
types of hypertension. 

The new research was conducted using Rhesus 
monkeys and African Green vervet monkeys. Pres- 
ence of one of the nation's largest primate facilities at 
Bowman Gray permitted studies on endoxin to be 
expanded to animals whose systems are similar to that 
of humans. 

Using hypertensive monkeys and a control group of 
monkeys with normal blood pressure, the researchers 
found a significant increase in the endoxin level in the 
blood from monkeys with hypertension. Generally, it 
was found that the higher the blood pressure, the 
higher the endoxin level. 

The research also suggests that endoxin may be 
important in regulating both the systolic blood 



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504 



Vol. 42, No. 7 



pressure and the diastolic blood pressure. 

Work at Bowman Gray is continuing to analyze the 
structure of endoxin and to further evaluate its role in 
human hypertension. 

* * * 

Plans are under way for establishing a center for 
adolescent medicine at the Bowman Gray/Baptist 
Hospital Medical Center. 

The center is being initiated through a gift from the 
Brenner family of Winston-Salem and will be known 
as the Brenner Center for Adolescent Medicine. 

Initial focus of the center will be on both the devel- 
opment of a required teaching program in adolescent 
medicine for medical students and physicians who are 
training in pediatrics, and on the establishment of an 
adolescent medicine clinic at North Carolina Baptist 
Hospital. 

Plans call for the future expansion of the center to 
include research on problems with adolescents. 

Dr. Jimmy L. Simon, professor and chairman of the 
Department of Pediatrics, and a specialist in adoles- 
cent medicine will be co-directors of the center. 

It will be the first center for adolescent medicine in 
North Carolina. There are only 26 such centers in the 
nation, two of which are in the southeast. 



Dr. William H. Boyce, professor of urology at 
Bowman Gray, has been given one of the highest 
awards for achievement in urology. 

He was presented the Barringer Medal of the 
American Association of Genito-Urinary Surgeons 
during the organization's annual meeting. 

The award, given for outstanding contributions in 
the advancement of urology, is presented in memory 
of Dr. Benjamin S. Barringer, noted New York 
urologist who died in 1953. 

The following year, the Barringer Award was 
created and 20 bronze medals were cast for sub- 
sequent use. The first recipient was Dr. Charles Hug- 
gins, a Nobel laureate. 

Boyce, who heads Bowman Gray's Section on 
Urology, is a former winner of the Hugh Hampton 
Young Award of the American Urological Associa- 
tion. He also is a six-time winner of research awards 
from that association. 

He is president of the Clinical Society of Genito- 
Urinary Surgeons. 

Boyce is recognized for a surgical technique he 
developed which enables the surgeon operating on a 
kidney to make the incision without interfering signifi- 
cantly with blood vessels in the kidney. 

Boyce's section also has pioneered use of ultra- 
sound in the early detection and diagnosis of prostatic 
cancer and other diseases of the prostate. 



"The Basic Atlas of Cross-Sectional Anatomy" by 
Bowman Gray faculty members has been awarded a 
certificate of excellence from the Association of 
American Publishers (AAP). 

July 1981, NCMJ 



The book was prepared by Dr. Walter J. Bo, profes- 
sor of anatomy and senior author: Dr. Isadore Mes- 
chan, professor of radiology; and Dr. Wayne A. 
Krueger, associate professor of anatomy. Illustrations 
were coordinated by George C. Lynch, professor of 
medical illustrations and director of the Department of 
Audio-visual Resources. 

The book won honorable mention for excellence in 
design and production in the AAP's competition for 
1980 books. The book was published by W. B. Saun- 
ders Company of Philadelphia. 



Dr. Robert L. Dixon, associate professor of radiol- 
ogy (physics), has been elected to the Board of Direc- 
tors of the American Association of Physicists in 
Medicine. 



Dr. Gary G. Poehling. assistant professor of or- 
thopedic surgery, has been elected to the editorial 
board of "Arthroscopy Video Journal, Inc." 



Dr. Richard W. St. Clair, professor of pathology 
(physiology), has been selected to serve as chairman 
of the National Heart, Lung and Blood Research Re- 
view Committee B for a one-year term beginning in 
July, 1981. 



Dr. George D. Rovere, associate professor of or- 
thopedic surgery, has been selected by the American 
Board of Orthopedic Surgery, Inc., as an examiner 
trainee for the 1981 Certifying Examination. 





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Celia Snavely, instructor in medicine (medical so- 
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of Hospice of Greensboro, Inc., for a three-year term. 



the chapter's annual meeting. Peggy Werner. R.N. in ' 
the Section on Rheumatology, was elected to the [I 
Medical Administration Council of the chapter. | 



Dr. Thomas E. Sumner, associate professor of 
radiology and pediatrics, was awarded a Certificate of 
Merit for his scientific exhibit on "Real-Time Sonog- 
raphy of Congenital Cystic Kidney Disease." It was 
presented at the meeting of the American Roentgen 
Ray Society. 



Dr. Elias G. Theros, professor of radiology, has 
been selected as an honorary fellow of the Nether- 
lands Radiology Society. He is only the second 
American ever to receive this honor. He was cited for 
his innovations in radiologic education and for his 
prominence in international radiology education, and 
was awarded the illuminated scroll of the Netherlands 
Radiology Society. He spoke on "Radiologic Analysis 
in Metabolic Diseases of the Bone" for the society's 
oration in Utrecht, The Netherlands. 



Dr. Robert A. Turner Jr., associate professor of 
medicine (rheumatology), was elected president of the 
North Carolina Chapter of the Arthritis Foundation at 



News Notes from the- 



EAST CAROLINA UNIVERSITY 
SCHOOL OF MEDICINE 



Several members of the Department of Anatomy 
attended the American Association of Anatomists and 
Chairmen's meeting in New Orleans April 19-24. Rep- 
resenting the department were Dr. Carl R. Morgan, 
professor and chairman, Drs. Irvin E. Lawrence and 
Hubert W. Burden, professors of anatomy, and Dr. 
Max C. Poole, assistant professor of anatomy. 

Lawrence presented "Is the Vagus Nerve a Com- 
ponent of the Hypothalamo-Hypophyseal-Ovarian 
Axis?," a paper co-authored by Burden. Poole pre- 
sented "Cytomorphometric Analysis of Pancreatic 
Islet Tissue from Alloxan Diabetic Rats." 



Dr. R. Stephen Porter, assistant professor of family 
medicine, is the author of "Disopyramide: Therapeu- 
tic Use and Serum Concentration Monitoring," a 



Since 1916, Saint Albans Psychiatric Hospital has been 
building on a tradition of quality care for adults and adolescents. 
A private, nonprofit hospital. Saint Albans is dedicated 
to meeting the unique needs of each patient. 

THEFUTURECOMESFAST. 



In 1980, Saint Albans 
opened a $7,8 million 
building with 162 beds 
and all clinical facilities. 
Our expanded programs 
include adults, adoles- 

Emergency services 
available at all times, 



cents, substance abuse, 
and geriatrics. We are 
also studying expansion 
in other areas as we 
prepare for a new era of 
service, 

ROLFE B. FINN, M.D. Medical Director 
ROBERT L, TERRELL, JR, Administrator 



Saint Albans Psychiatric Hospital 

P.O. Box 3608 Radford, Virginia 24141 



506 



Vol. 42, No. 7 



Jl 



chapter in Individualizing Drug Therapy: Practical 
Application of Drug Monitoring published by Gross, 
Townsend and Frank. 

* * * 
Dr. L. E. Masters, associate professor of family 
medicine, presented a talk on "Teaching Techniques" 
at the Teaching Practice Management Conference in 
Kansas City, Mo. The conference was sponsored by 
the American Academy of Family Residency Assis- 
tants Programs. 

An article by Dr. Robert Brame, professor and 
chairman of the Department of Obstetrics and Gyne- 
cology, Dr. Jarlath MacKenna, assistant professor of 
obstetrics and gynecology, and Dr. Charles Hodson, 
assistant professor of obstetrics and gynecology, 
appeared in the April issue of the Journal of American 
College of Obstetrics and Gynecology. The article is 
entitled "Clinical Utility of Fetal Lung Maturity Pro- 
file." * * * 

Dr. C. Tate Holbrook, assistant professor of pediat- 
rics, presented "Advances in Pathology" at the 
Childhood Cancer Conference sponsored by the 
American Cancer Society in Charlotte April 9. 



Dr. A. Mason Smith, associate professor of micro- 
biology, was a guest speaker at Lynchburg College, 



Lynchburg, Va.. in March. His topic was "Applica- 
tion of Immunology to Medicine." 



Dr. Paul D. Mozley, professor of obstetrics and 
gynecology, published "Malignant Hyperthermia 
Following Intravenous lodinated Contrast Media: 
Report of a Fatal Case" in the spring issue of Diag- 
nostic Gynecology and Obstetrics. Mozley also at- 
tended the ninth annual conference of Psychosomatic 
Obstetrics and Gynecology and introduced the resi- 
dent prize paper. The conference was held at the 
Temple University Conference Center in Philadel- 
phia, Pa. 

* * * 

Dr. John Moskop, assistant professor of pediatrics 
and humanities, recently published "Mill and Hart- 
shorne" inProcess Studies. Moskop also is the author 
of "Medicine. Ethics, and the Living Body: A Re- 
sponse to Thomasma and Pellegrino" in the February 
issue of the Journal of Metamedicine. 



Dr. Uwe MiJller, assistant professor of microbiol- 
ogy, recently was a guest speaker at N.C. Wesleyan 
College, Elon College and Presbyterian College, 
Clinton, S.C., where he presented "Genetic En- 
gineering in Modern Society: Its Role in Basic Re- 
search, Agriculture and Medicine." 



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July 1981, NCMJ 



507 



Dr. Max C. Poole, assistant professor of anatomy, 
has received a $46,131 grant from the National Insti- 
tutes of Health to study "Morphometry of Gonado- 
tropes During Hyperprolactinemia." 



Dr. Paul L. Fletcher, associate professor of micro- 
biology, was a guest speaker at Hampden-Sydney 
College, Hampden-Sydney, Va. He presented 
"Evolution of a Metabolic Path: Degradation of 
Aromatic Compounds." 



Dr. Irvin L. Blose, professor of psychiatry , directed 
a seminar on "Research in Alcoholism" at the April 
meeting of the N.C. Alcohol and Drug Foundation 
held at the Water B. Jones Alcoholic Rehabilitation 
Center in Greenville. 



Several members of the departments of microbiol- 
ogy, biochemistry, physiology and anatomy attended 
the 65th annual meeting of the Federation of American 
Societies for Experimental Biology in Atlanta. 

Presenting papers and poster sessions were Dr. 
A. Mason Smith, associate professor of microbiol- 
ogy, "The Distribution and Kinetics of Immunoglob- 



ulin Isotypes Carrying the M467 Idiotype in the Genus 
Mns Following Immunization with Salmonella 
Flagellin"; Dr. Leonard S. English, assistant profes- 
sor of microbiology, "Production of Immunoregula- 
tory Factors in the First 12 Hours of Immune Re- 
sponses in \/\'o": Dr. Subhash C. Gautam. post- 
doctoral fellow in microbiology, "Progressive Growth 
of a Weakly Immunogenic Fibrosarcoma Induces 
Immuno-Suppression in Mice": Dr. G. Lynis Dohm, 
associate professor of biochemistry, "The Effect of 
Acute Exercise on Amino Acid Metabolism"; Dr. 
Hisham A. Barakat, associate professor of 
biochemistry, "Fatty Acid Metabolism During Re- 
covery from Acute Exercise"; Dr. George J. Kas- 
perek, associate professor of biochemistry, "Role of 
Lysosomes in the Loss of Major Constituents of Liver 
During Exercise"; Dr. John Yeager, assistant profes- 
sor of physiology, "Verapamil Prevents Isoproter- 
enol-induced Cardiac Failure"; Dr. David L. 
Beckman, professor of physiology, and Dr. Dan Crit- 
tenden, research associate in physiology, presented 
two poster sessions. "Stellate Ganglion Influence on 
Static Compliance and Surface Layer Lipids in Cat 
Lungs" and "Protection from Seizures Due to High 
Pressure Oxygen by Clonazepam and Propylene 
Glycol." 

Representing the Department of Anatomy at the 



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has greater 
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Ascriptin 


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Garnett, W.R.: "Antacids," in Apple, W. (ed): Handbool< of 
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BRISTOL-MYERS II PROFESSIONAL PRODUCTS 



meeting were Dr. Hubert W. Burden, professor of 
anatomy, Dr. Thomas M. Louis, associate professor 
of anatomy, and Dr. Lamar T. Blankenship, research 
associate. Burden was co-author of a paper presented 
by Dr. Charles A. Hobson, assistant professor of 
obstetrics and gynecology, entitled "Serum Steroid 
Hormone and Gonadotropin Concentrations During 
Growth of Transplantable Prolactin Secreting 
Tumors." 

Louis and Blankenship presented a poster session 
on "Plasma Progesterone and Progesterone Binding 
Protein During the Estrous Cycle and Pregnancy in 
Dolichotis Patagona (Mara)." 



Dr. Zubie W. Metcalf, director of the Center for 
Student Opportunities, recently was named chairper- 
son of the Southern Regional Nominating Committee 
of the Minority Affairs Section of the Association of 
American Medical Colleges. 

* * * 

Dr. Donald Barnes, assistant professor pharmacol- 
ogy, published "Effects of Anionic Polymeric Drugs 
and Other Immunoactive Agents on Hepatic Micro- 
somal Mixed-Function Oxidases," a chapter in 
Anionic Polymer Drugs published last fall by John 
Wiley & Sons. 



News Notes from the 

UNIVERSITY OF NORTH CAROLINA- 
CHAPEL HILL SCHOOL OF MEDICINE 
AND 
NORTH CAROLINA MEMORIAL HOSPITAL 



Medical scientists at the University of North Caro- 
lina at Chapel Hill last year ranked among the top U.S. 
medical school faculties in the percentage of approved 
research projects funded by the National Institutes of 
Health. 

Their research proposals ranked fifth in terms of 
overall quality and achieved an NIH funding success 
rate that was ninth best among American medical 
schools. 

These statistics are contained in the latest Informa- 
tion for Management, Planning, Analysis and Coordi- 
nation Report compiled by NIH for institutions with 
NIH grants. The IMPAC Report prepared for each 
school does not disclose the ranking of other schools. 

NIH is by far the single largest source of funds for 
health-related research in this country. The total value 
of current NIH grants to the UNC-CH School of 
Medicine is $17.9 million. 

During fiscal year 1980, four out of five grant appli- 
cations submitted by the School of Medicine were 
approved in the first round of NIH's review process. 



Of those initially approved, 44.8% were funded, giving 
the medical school the ninth best NIH funding rate. 

For the purpose of fund allocation, projects are 
ranked in order of merit or importance, as judged by 
NIH's research evaluation groups. The higher a proj- 
ect's priority rating, the more likely it is to be funded. 

Last year UNC-CH medical research proposals re- 
ceived a combined priority score that was the fifth 
highest among the nation's 66 medical schools sub- 
mitting at least 50 grant applications. 

"The priority score is really the outstanding figure 
in these statistics, as far as we're concerned," said 
Clarence Stover, associate dean for administration of 
the UNC-CH School of Medicine. "We think it is a 
good indication of the competitiveness and relative 
quality of our research activities here." 

Dr. Stuart Bondurant, dean of the medical school, 
noted that the scientists who review grant proposals 
for NIH are, themselves, faculty members at medical 
schools across the country and are selected by NIH 
for their expertise in particular areas of research. 

"Our high NIH ranking reflects the fact that the 
research engaged in by our faculty is recognized by 
their peers as being of exceptionally high quality and 
potential," Bondurant said. 

"We have faculty members who are known, 
throughout the world in many cases, as leading au- 
thorities in their fields and investigators of the highest 
caliber." 

Bondurant added that he is confident the UNC-CH 
School of Medicine will continue as a national leader 
in biomedical research. 

"The reputation for excellence that our research 
programs have earned will help ensure that we will 
continue to attract talented, energetic faculty mem- 
bers to take up the search for solutions to some of 
mankind's most difficult health problems." 



Dr. Kenneth M. Brinkhous, alumni distinguished 
professor of pathology emeritus, was awarded the 
highest honor of his specialty April 14 in Atlanta. 

Brinkhous received the Gold Headed Cane Award 
of the American Association of Pathologists, an award 
created in 1919 to honor "a physician who represents 
the highest ideals in medicine and pathology." The 
award was presented at a dinner of the AAP, a mem- 
ber of the Federation of American Societies for Ex- 
perimental Biology (FASEB). 

World-renowned for his pioneering studies of blood 
coagulation which led to the first effective control of 
hemophilia, Brinkhous is a past president of FASEB 
and also of the American Association of Pathologists 
and Bacteriologists and the American Society for Ex- 
perimental Pathology, the two groups that merged to 
form AAP in 1976. 

Brinkhous has devoted nearly half a century as 
leader of a basic and clinical research group devoted to 
investigation of blood clotting mechanisms and 
methods of diagnosing and treating hemostatic de- 
fects. 



July 1981, NCMJ 



511 



His work on hemophilia led to development in 1947 
of a unique experimental colony of hemophilic dogs at 
the School of Medicine, one of the world's major 
multidisciplinary clinic research centers for the study 
of bleeding and clotting disorders. The center's re- 
search led to commercial production of a concentrate 
of the antihemophilic factor that has made it possible 
for hemophilic patients to treat themselves at home to 
prevent crippling and to undergo surgical procedures 
without the threat of hemorrhage. 

Brinkhous and his colleagues developed the partial 
thromboplastin time test that now is used worldwide 
for rapid screening of potential bleeders. In recent 
years, Brinkhous has studied platelets in hemostatic 
and thrombotic disorders, and his work on measure- 
ment of platelet aggregation has led to simplified clini- 
cal testing for von Willebrand's disease. 

Born in Clayton County, Iowa, Brinkhous received 
his A.B. and M.D. degrees from the University of 
Iowa. He was a member of the pathology department 
there from 1932 to 1946, except for five years in the 
Army Medical Corps during World War II. In 1946 he 
accepted a position as chairman of the Pathology De- 
partment of UNC-CH and has been instrumental in 
training practicing pathologists and leading a large 



number of investigators in the field of thrombosis and 
hemorrhage. 

In 1967, Brinkhous was awarded an honorary doc- 
torate of science by the University of Chicago. He was 
elected to membership in the National Academy of 
Sciences in 1972 and is a senior member of the Insti- 
tute of Medicine. 

He has received 20 honorary awards including the 
Ward Burdick and H. P. Smith Memorial Lecture 
Awards of American Society of Clinical Pathologists, 
the Distinguished Alumni Award of the University of 
Iowa, and the Oliver Max Gardner Award of the Uni- 
versity of North Carolina Board of Governors. 

Currently the chief editor of Archives of Pathology 
and Laboratory Medicine and editor of the Year of 
Pathology and Clinical Pathology. Brinkhous serves 
on the editorial boards of many other journals, in- 
cluding the Journal of the American Medical Associa- 
tion, International Review of Experimental Pathol- 
ogy, and Perspectives in Biology and Medicine. He 
has published 274 papers and chapters in scientific 
journals and texts dating from 1934 to 1980. 
* * * 

Dr. William E. Easterling Jr., chief of staff of North 
Carolina Memorial Hospital since 1974, has been 



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512 



Vol. 42. No. 7 



named associate dean for clinical affairs at the School 
of Medicine. 

The appointment, effective April 1 , was announced 
by Dr. Stuart Bondurant, dean of the medical school. 

"The coming months will be a time of great change 
for our medical school," Bondurant said. "Dr. Eas- 
terling will assume leadership in the clinical area as we 
address such issues as changes in patterns of support, 
the effectiveness of teaching programs, and relation- 
ships with referring physicians and our local commu- 
nity." 

Easterling's new responsibilities will encompass 
areas formerly overseen by Dr. William Cromartie, 
who has served as an associate dean in charge of 
clinical sciences for the medical school only. The dean 
said this move is "part of an administrative reorgani- 
zation designed to bring clinical affairs in the hospital 
and the school of medicine into closer relationship 
under the leadership of the same person." 

He said Cromartie will "retain his involvement in 
the senior administration of the medical school, and 
will assume new duties with responsibilities equiva- 
lent to his work in the clinical area." 

Easterling earned the A.B. degree at Duke and re- 
ceived his medical degree from the University of 
North Carolina in 1956. He has served on the faculty 
of the medical school since 1964, and in 1971 was 
named professor in the Department of Obstetrics and 
Gynecology. He has held numerous administrative 
offices in the medical school. 

As chief of staff , Easterling will continue his role as 
chief officer of the hospital's medical/dental staff. 
Dean Bondurant said Easterling's additional respon- 
sibilities as associate dean "will involve an executive 
relationship with all of the medical school's patient 
care departments in coordinating and overseeing 
clinical efforts, research programs, budgets and fac- 
ulty appointments." 

* * * 

When plans were being laid for the formation of the 
Cancer Research Center at the University of North 
Carolina at Chapel Hill in 1975, the Burroughs 
Wellcome Fund was among the first to pledge finan- 
cial support. Recently the fund gave the University 
$200,000 of its $250,000 pledge to help finance con- 
struction of a facility to house the Cancer Research 
Center. 

Noting receipt of the contribution. Dr. Stuart Bon- 
durant, dean of the School of Medicine, said, "The 
Burroughs Wellcome Fund originally planned to make 
this contribution over a five-year period. We are 
grateful they have decided instead to make the first 
four installments at this time. Because the financial 
needs are extremely great at this stage, this support is 
not only generous, but also quite literally vital." 

Construction is expected to begin later this year on 
the UNC-CH cancer research building to be known as 
the Lineberger Cancer Research Center. The facility 
is expected to be completed in 1984 and will house the 
laboratories of the center's original core faculty now 
scattered throughout the UNC-CH medical center. 



Bondurant noted that the Burroughs Wellcome 
Fund has supported cancer center activities for a 
number of years. 

"The sponsorship of the Burroughs Wellcome Fund 
has enabled us to bring distinguished visiting profes- 
sors to campus, thus benefitting medical education 
throughout the region," he said. 



Thirty years of black student enrollment was com- 
memorated April 24 at the School of Medicine. A 
series of activities was planned, culminating with the 
first Lawrence ZoUicoffer Lecture. 

Dr. Louis W. Sullivan, dean of the Morehouse Col- 
lege School of Medicine in Atlanta, delivered the 
ZoUicoffer Lecture. His topic was "Minority Physi- 
cians in the 1980s: Prospects and Challenges." 

Sullivan also participated in rounds and in a number 
of meetings with faculty, students and alumni of the 
School of Medicine. His visit was sponsored by the 
Student National Medical Association, an organiza- 
tion involved in areas of specific interest to black 
students, in conjunction with the School of Medicine. 

The ZoUicoffer Lecture is named in honor of the late 
Dr. Lawrence ZoUicoffer, the fourth black student to 
graduate from the School of Medicine. 

A native of Halifax County, ZoUicoffer graduated 
from North Carolina A. and T. State University in 
1948 at the age of 17. Following military service and 



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several years in the teaching profession, he enrolled in 
the University of North Carolina at Chapel Hill. 

His post-graduate training included a pediatrics 
fellowship at The Johns Hopkins University Hospital, 
and Zollicoffer remained in Baltimore to practice 
pediatrics. 

He became a prominent physician, known espe- 
cially for his humanitarian accomplishments. 

Garwyn Medical Center, of which Zollicoffer was a 
founder, was one of the first black-owned and oper- 
ated medical centers in the Baltimore area and re- 
ceived national recognition. He also was a member of 
Freedom House, one of the nation's oldest organiza- 
tions for the advancement of civil rights. Zollicoffer 
died of cancer in 1976. 

One of Zollicoffer' s four children, Michael L. Zol- 
licoffer, currently is a student in the UNC-CH School 
of Medicine. Other members of the family also were in 
Chapel Hill for activities connected with the Zollicof- 
fer Lecture. 

The first black student in the School of Medicine 
was Dr. Edward O. Diggs, who enrolled in 1951. Now 
a Winston-Salem physician, Diggs graduated in 1956 
and was the first of 1 1 1 minority students to receive 
M.D. degrees from UNC-CH during the past 30 years. 

For a number of years, the School of Medicine at 
UNC-CH has consistently had one of the highest 



minority enrollments among all traditionally white 
medical schools in the nation. 

Presently, 13% of UNC-CH's medical student en- 
rollment is black and other minorities are represented 
by an additional 2.6%. 



Dr. Thomas B. Bamett has been named Bonner 
Professor of Pulmonary and Allied Diseases in the 
School of Medicine. University Chancellor Chris- 
topher C. Fordham III announced the appointment. 

Barnett is the first professor to hold the Bonner 
professorship which was established last year by a gift 
from Dr. M. D. "Rabbit" Bonner and Blanche Hanff 
Bonner of Greensboro, both UNC-CH alumni. 

Barnett joined the medical school faculty in 1952 as 
an instructor in medicine. He was promoted to assis- 
tant professor in 1954, associate professor in 1958 and 
full professor in 1964. Barnett headed the division of 
pulmonary medicine from 1954-75. 

He spent 1966-67 as a National Heart Institute Spe- 
cial Fellow in Respiratory Physiology at the Univer- 
sity of Copenhagen, Denmark. He was awarded a 
Kenan Research Leave for 1975-76 and returned to 
Copenhagen to spend the year at the August Krogh 
Institute. 

A native of Tennessee, Barnett graduated from the 




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514 



Vol. 42, No. 7 



University of Tennessee in 1944 and earned his M.D. 
degree from the University of Rochester (N.Y.) in 
1949. 

His current research deals with ventilatory 
stimulus-response relationships in the presence of ab- 

f normal respiratory mechanics. 

I In addition to teaching in the field of pulmonary 
medicine. Bamett's special interests have related to 
ithe use of low density gases in localizing sites of air- 
way obstruction and to the role of protease inhibitors 
in the pathogenesis of obstructive lung diseases. 



Dr. Roger L. Lundblad has been named associate 
director of the Dental Research Center. 

Lundblad is professor of pathology and biochemis- 
try. School of Medicine, and professor of oral biology 
in the Department of Periodontics, School of Den- 
tistry. He was appointed to the staff of the center in 
1968 and became acting associate director in 1978. He 
also is associate director of the Center for Thrombosis 
and Hemostasis. 

His research concerns protein chemistry and blood 
coagulation. 

Before coming to Chapel Hill. Lundblad was a re- 
search associate at Rockefeller University and the 
University of Washington at Seattle. 

A California native, he earned his B.S. degree in 
chemistry from Pacific Lutheran University in 1961 
and his Ph.D. from the University of Washington at 
Seattle in 1965. 



Six faculty members attended the annual combined 
meeting of the North Carolina Chapter of the Ameri- 
can College of Physicians and the North Carolina So- 
ciety of Internal Medicine Feb. 14-15 at Duke Univer- 
sity Medical Center. 

Dr. Stuart Bondurant, dean of the School of Medi- 
cine, was guest speaker. He spoke on "Some Current 
Issues in American Medicine." Dr. Henry P. Nathan, 
chief resident and clinical instructor, participated in a 
panel discussion. Dr. Eugene M. Bozymski, professor 
of medicine, spoke on "G.I. Complications of Dia- 
betes Mellitus." 

Dr. John T. Gwynne, assistant professor of medi- 
cine, spoke on "Hyperlipidemia and Atherosclerosis 
in Diabetes." Dr. William B. Wood, director of con- 



tinuing medical education and alumni affairs, and Dr. 
James A. Bryan, professorofmedicine, also attended. 



Doug Anderson, assistant director of professional 
support services, radiology, has been elected for a 
three-year term as a member of the board of directors 
of the Nuclear Medicine Technology Certification 
Board. 

AMERICAN COLLEGE OF PHYSICIANS 

Dr. Stuart Bondurant, dean of the University of 
North Carolina School of Medicine, was honored with 
a Mastership in The American College of Physicians at 
the annual session in Kansas City in April. He is 
immediate past president of the organization. Of the 
51,000 members — doctors of internal medicine, re- 
lated specialists and physicians-in-training — only 159 
hold the rank of Master. Also at the Kansas City 
meeting. Dr. Joseph Johnson, chairman of the De- 
partment of Medicine at Bowman Gray School of 
Medicine, was chosen North Carolina's governor 
elect. Three other North Carolina physicians — Drs. 
William Hopper of Greensboro, James Wortman of 
Wilmington and Joe Moore of the Duke University 
Medical Center — were elected Fellows of the college. 
The following physicians are new members of the 
organization: Drs. David Boemer, Clyde Guthrow 
and Nelson Rassi of the Duke University Medical 
Center: Dr. Edward Bradford of Charlotte: Dr. 
Charles Crumley of Lincolnton: Dr. Tom Carmody of 
MoreheadCity: Dr. JafarGhassemianof Fayetteville; 
Dr. John Holston of Cherry Point: and Dr. Charles 
Lefler of Brevard. 

FEDERATION OF STATE MEDICAL BOARDS 

Dr. Bryant L. Galusha of Charlotte was installed as 
president of the Federation of State Medical Boards of 
the United States at its annual meeting in Chicago in 
April. A member of the N.C. Board of Medical Ex- 
aminers from 1968 through 1980, he is widely recog- 
nized for contributions to the field of medical licen- 
sure. He is director of medical education at Charlotte 
Memorial Hospital and holds appointments as clinical 
professor of pediatrics at the University of North Car- 
olina School of Medicine, assistant professor of food 
and nutrition at Winthrop College in Rock Hill, S.C., 
and adjunct professor of nursing at the UNC- 
Charlotte School of Nursing. 



July 1981. NCMJ 



515 



In Msmatmm 



RUrUS PRESTON SYKES, M.D. 

Dr. Rufus Preston Sykes, a family practitioner in 
Asheboro, died February 9, after a short illness. 

He was born December 9, 1899, in Conway, North 
Carolina, to the late Carrie Boone and John Addison 
Sykes. 

Dr. Sykes attended the University of North Caro- 
lina for his undergraduate work and graduated from 
Tulane Medical School. He interned at City Memorial 
Hospital in Winston-Salem and took his residency at 
Baptist Hospital in Winston-Salem. He had been 
president of the Randolph County Medical Society, a 
member of the Randolph Hospital medical staff, a 
director of the Randolph County Board of Health, 



a member of the Contemporary Society of Medicine 
and member of the Royal Society of Medicine. He was 
president of the board of trustees of the First 
Methodist Church of Asheboro. 

Dr. Sykes was a dedicated physician who provided 
excellent medical care to his patients for over 50 
years. He was loved by his patients, his colleagues and 
the community at large. He will be missed by one and 
all who had the pleasure of knowing him. 

Surviving are his wife. Dr. Jean Trogdon Sykes; a 
brother, John Sykes of Conway; sisters, Mrs. Lucy 
Williamson of Turkey, Mrs. Maggie Gay of Seaboard, 
and Mrs. Mary Rich and Mrs. Ruth Story both of 
Conway. 

Randolph County Medical Society 



1 1 

I 



516 



Vol. 42, No. 7 



Classified Ads 



BM MAG Card Systems, Typewriters, Selectrics and Electronic. All 
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llEXAS — IMMEDIATE OPENINGS in Dallas for Ophthahnologist, 
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PHYSICIAN ASSISTANTS — Would a Physician Assistant be of 
benefit to your practice? The North Carolina Academy of Physi- 
cians' Assistants responds promptly to physician inquiries. Con- 
tact: Paul C. Hendrix, P.A.-C, Chairman, Employment Commit- 
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NORTH CAROLINA — Family Practice/Emergency Medicine. 
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VIRGINIA — Unique opportunity. Emergency Medicine. Modern 
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July 1981, NCMJ 



517 



Index to 
Advertisers 



Air Force 503 

Blue Cross & Blue Shield of N.C 463 

Bristol-Myers Professional Products 465, 466, 

509, 510 

Burroughs Wellcome Company 457, 498 

Charlotte Chest Laboratory 502 

Charlotte Treatment Center 518 

Children's Home Society of N.C 499 

Crumpton, J. L. & J. Slade, Inc 449 

Fellowship Hall 512 

Golden-Brabham Insurance Agency 458 

Graphic Cardiology 455 

Holly Hill Hospital 507 

Lilly, Eli & Company 462 

Mandala Center 446 

Mead Johnson & Company 461 



Medical Mutual Insurance Company 450 

Mutual of Omaha 447 

National Medical Enterprises, Inc 497 

Ortega Pharmaceutical Company 508 

Plyler Financial Services 505 

Provident Mutual Life Insurance Co 513 

Ramada Inn Downtown 456 

Roche Laboratories Cover 2, 443, 444, 

Cover 3, Cover 4 

Saint Albans Psychiatric Hospital 506 

Upjohn Company 491 , 492 

Vyquest Development Corp 504 

Willingway, Inc 514 

Winchester Surgical Supply Co., 

Winchester-Ritch Surgical Co 445 

Wyeth Laboratories 451, 452, 500, 501 



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James F. Emmert, Executive Director 
Rex R. Ta^gart. M.D., Medical Director 



518 




Vol. 42, No. 7 



-imbitrol 

Blefs 5-12.5 eoch containing 5 mg chlordiazepoxide and 12,6 mg amitriplyline 

(as ttie hydrochloride salt) 
3I8IS 10-25 each containing 10 mg chtodiazepoxide and ,25 mg amitriptyline 

(OS the hydrochlonde salt) 



(g 











1 anxious depression, 

SPECIFIC FOR THE NONPSYCHOTIC PATIENT 



its the picture of 

nxiety/depression 

orrelotion 

ost patients with a mood disorder have a 
lixture of anxiety and depression. One 
inician' found a correlation of 0.7 in 
ixiety and depression scores; another^ has 
stimated that 7 of 10 nonpsychotic 
apressed patients are also anxious. For the 
jal symptomatology of anxious depression, 
mbitrol provides dual medication. 



More appropriate 
for the nonpsychotic 
depressed and 
anxious patient 

Limbitrol contains both amitriptyline, specific 
for symptoms of depression, and a 
benzodiazepine, specific for the symptoms of 
anxiety. Thus it is a better choice than other 
dual agents for anxious depression that 
contain a phenothiazine, a class of 
antipsychotic dmgs less specific for anxiety 
and now generally avoided in nonpsychotic 
patients. ^-^ 



Avoids the risl< of tardive 
dyskinesia carried 
by the phenothiazine 
combinations 

The causal relationship between the 
phenothiazines and other extrapyramidal 
side effects, including tardive dyskinesia, is 
well established. In contrast, the reported 
incidence of these adverse reactions with 
Limbitrol or either of its components is rare. 

References: 1. Cloghom J Psychosomatics 1 / 438-441, 
Sept-Oct 1 970 2. Rickels K Drug treotment of onxiety, in 
Psychopharmacology in the Practice of Ivledicine, edited by 
Jorvik ME NewYort(, Appleton-Century-Crofts, 1977, p 316 
3. Boldessarini RJ, Tarsy D Tardive dyskinesia, in 
Psychopharmacology A Generation of Progress, edited by 
Lipton MA, Dilutoscio A, Killam KF New York, Raven Press, 
1978, p 999 



: f ifore prescribing, please consult complete 
oduct information, a summary of which 
Hows: 
1: dications: Relief of moderate to severe depres- 
: 3n associated witti moderate to severe anxiety, 
) sntraindicatlons: Known hypersensitivity to ben- 
• idiazepines or tricyclic antidepressants Do not 
■,e with monoamine oxidase (MAO) inhibitors or 
thin 14 days following discontinuation of IvIAO 
.Tibitors since hyperpyretic crises, severe con- 
iilsions and deaths have occurred with con- 
omitant use; then initiate cautiously, gradually 
.creasing dosage until optimal response is 
;hieved, Contraindicated during acute recovery 
lase following myocardial infarction 
arnings: Use with great care in patients with 
story of urinary retention or angle-closure 
aucoma. Severe constipation may occur in 
Jtients taking tricyclic antidepressants and anti- 
lolinergic-type drugs Closely supervise car- 
ovascular patients (Arrhythmias, sinus tachycar- 
a and prolongation of conduction time reported 
Ih use of tricyclic antidepressants, especially 
gh doses, Ivlyocardial infarction and stroke 
ported with use of this class of drugs,) Caution 
itients about possible combined effects with 
:ohol and other CNS depressants and against 
izardous occupations requiring complete mental 
ertness (e,g,, operating machinery, driving) 
Usage In Pregnancy: Use of minor tran- 
quilizers during the first trimester should 
almost always be avoided because of 
Increased risit of congenital malforma- 
tions as suggested in several studies 
Consider possibility of pregnancy when 
instituting therapy; advise patients to 
discuss therapy if they intend to or do 
i become pregnant. 

'nee physical and psychological dependence to 
ilordiazepoxide have been reported rarely, use 
lution in administering Limbitrol to addiction- 
one individuals or those who might increase 
')sage; withdrawal symptoms following discon- 
(luation of either component alone have been 
■ ported (nausea, headache and malaise for 
jnitriptyline. symptoms [including convulsions] 
jmilar to those of barbiturate withdrawal for 
plordiazepoxide). 



Precautions: Use with caution in patients with a 
history of seizures, in hyperthyroid patients or those 
on thyroid medication, and in patients with im- 
paired renal or hepatic function Because of the 
possibility of suicide in depressed patients, do not 
permit easy access to large quantities in these 
patients Periodic liver function tests and blood 
counts are recommended during prolonged treat- 
ment Amitriptyline component may block action of 
guanethidine or similar antihypertensives. Con- 
comitant use with other psychotropic drugs has not 
been evaluated: sedative effects may be additive 
Discontinue several days before surgery. Limit 
concomitant administration of ECT to essential 
treatment See Warnings for precautions about 
pregnancy, Limbitrol should not be taken during 
the nursing period Not recommended in children 
under 12 In the elderly and debilitated, limit to 
smallest effective dosage to preclude ataxia, over- 
sedation, confusion or anticholinergic effects. 
Adverse Reactions: Most frequently reported are 
those associated with either component alone: 
drowsiness, dry mouth, constipation, blurred vision, 
dizziness and bloating. Less frequently occurring 
reactions include vivid dreams, impotence, tremor, 
confusion and nasal congestion. Many depressive 
symptoms including anorexia, fatigue, weakness, 
restlessness and lethargy have been reported as 
side effects of both Limbitrol and amitriptyline. 
Granulocytopenia, jaundice and hepatic dysfunc- 
tion have been observed rarely, 
The following list includes adverse reactions not 
reported with Limbitrol but requiring consideration 
because they have been reported with one or both 
components or closely related drugs 
Cardiovascular: Hypotension, hypertension, tachy- 
cardia, palpitations, myocardial infarction, arrhytti- 
mias, heart block, stroke. 
Psychiatric: Euphoria, apprehension, poor con- 
centration, delusions, hallucinations, hypomania 
and increased or decreased libido. 
Neurologic: Incoordination, ataxia, numbness, tin- 
gling and paresthesias of the extremities, extra- 
pyramidal symptoms, syncope, changes in EEG 
patterns 

Anticholinergic: Disturbance of accommodation, 
paralytic ileus, urinary retention, dilatation of uri- 
nary tract. 



Allergic: Skin rash, urticaria, photosensitization, 
edema of face and tongue, pruritus 
Hematologic: Bone marrow depression including 
agranulocytosis, eosinophilia, purpura, 
thrombocytopenia 

Gastrointestinal Nausea, epigastric distress, vomit- 
ing, anorexia, stomatitis, peculiar taste, diarrhea, 
black tongue 

Endocrine: Testicular swelling and gynecomastia in 
the male, breast enlargement, galactorrhea and 
minor menstrual irregularities in the female and 
elevation and lowering of blood sugar levels 
Other: Headache, weight gain or loss, increased 
perspiration, urinary frequency, mydriasis, jaun- 
dice, alopecia, parotid swelling 
Overdosage: Immediately hospitalize patient sus- 
pected of having taken an overdose Treatment 
is symptomatic and supportive l,V, administration 
of 1 to 3 mg physostigmine salicylate has been 
reported to reverse the symptoms of amitriptyline 
poisoning. See complete product information for 
manifestation and treatment. 
Dosage: Individualize according to symptom se- 
venty and patient response Reduce to smallest 
effective dosage when satisfactory response is 
obtained. Larger portion of daily dose may be 
taken at bedtime Single h.s. dose may suffice for 
some patients Lower dosages are recommended 
for the elderly 

Limbitrol 10-25. initial dosage of three to four 
tablets daily in divided doses, increased to six 
tablets or decreased to two tablets daily as re- 
quired, Limbitrol 5-12 5, initial dosage of three to 
four tablets daily in divided doses, for patients who 
do not tolerate higher doses. 
How Supplied: White, film-coated tablets, each 
containing 10 mg chlordiazepoxide and 25 mg 
amitriptyline (as the hydrochloride salt) and blue, 
film-coated tablets, each containing 5 mg chlor- 
diazepoxide and 12-5 mg amitriptyline (as the 
hydrochloride salt)— bottles of 100 and 500; 
Tel-E-Dose* packages of 100, available in trays of 
4 reverse-numbered boxes of 25, and in boxes 
containing 10 strips of 10, Prescription Paks of 50, 



ROCHE PRODUCTS INC, 
Manati, Puerto Rico 00701 



MORE DEPRESSION 
MEANS MORE ANXIETY.. 



The graph illustrates the close correlation 
between depression and anxiety derived 
through the MMPI and the Taylor Manifest 
Anxiety Scale in 100 nonpsychotic psychi- 
atric patients. The Coefficient of Correlation is 
0.7. As depression increased, so did the 
anxiety levels. 

—Adapted from Cloghorn J' 




A key reason why 

MORE PHYSICIANS ARE CHOOSING 

LIMBITROC 

Tablets 5-12.5 each containing 5 mg chlordiazepoxide and 12 5 mg amitnptyline 

(as ftie tiydrochloride salt) 
Tablets 10-25 eacti containing 10 mg chlordiazepoxide and 25 mg amitnptyline 

(as the hydrochloride salt) 




1. Cloghom J; Psychosomotics //.438-441, Sept-Oct 1£ 
Please see summary of product Information on Inside cc 






North Carolina 

MEDICAL JOURNAL 



he Official Journal of the NORTH CAROLINA MEDICAL SOCIETY D D D August 1981, Vol. 42, No. 8 



President's Acceptance Speech 541 

Josephine E. Newell, M.D. 

Original Articles 

Prescription Medication in the 
Workplace. Occupational 
Absenteeism, Accidents, and 
Performance When Using 
Non-Psychoactive and Psychoactive 

Medication 545 

Richard C. Proctor, M.D. 

Illness Onset and Levels of 

Health Care Provided: A Study 

of 213 Families 548 

Robert B. Taylor, M.D., 
Robert L. Michielutte, Ph.D., and 
Anne Herndon, Ph.D. 

Acute Beryllium Lung Disease 551 

William F. Hopper, M.D. 

Special Article 

Medical Care in North Carolina Jails 554 

Nancy Taylor, R.N., and 
Carleen Massey, R.N. 

Mini-Feature 

Toxic Encounters of the 
Dangerous Kind — More on 

Speeding 560 

Ronald B. Mack, M.D. 

Editorials 

John S. Rhodes, M.D 567 

Medicine in the Workplace 567 

The Price of Civilization or 
Your pH Hangs in the Balance . . 567 



Practice Management 

Paying Today Gives Patients 

a Pain 569 

NC-AMA Delegate's Report 

1981 Annual Meeting of the AM A 
House of Delegates Facing 570 

Bulletin Board 

New Members of the State Society 573 

What? When? Where? 573 

Auxiliary to the North Carolina 

Medical Society 575 

News Notes from the Bowman Gray 
School of Medicine of Wake 

Forest University 576 

News Notes from the Duke 

University Medical Center 579 

News Notes from the University of 
North Carolina-Chapel Hill 
School of Medicine and North 

Carolina Memorial Hospital 585 

News Notes from the East Carolina 

University School of Medicine . . 592 
American College of Cardiology . . . 595 
North Carolina Hospital Association 595 

In Memoriam 596 

Classified Ads 613 

Index to Advertisers 614 



1981 Committee Conclave: Sept. 23-27, 
Southern Pines 

1982 Conference for Medical Leadership: 

February 5-6, Winston-Salem 
1982 Annual Sessions: May 6-9, 
Pinehurst 



^19.6? 



Qn 






1 



Examine Me. I 



I 



During the past several years, I have heard my name mentioned 
in movies, on television and radio talk shows, and even at Senate 
subcommittee sessions. And I have seen it repeatedly in newspapers, 
magazines, and yes, best-sellers. Lately, whenever I see or hear the 
phrases "overmedicated society, " "overuse, " "misuse, " and "abuse, " my 
name is one of the reference points. Sometimes even the reference point 

These current issues, involving patient compliance or dependency- 
proneness, should be given careful scrutiny, for they may impede my 
overall therapeutic usefulness. As you know, a problem almost always 
involves improper usage. When I am prescribed and taken correctly, 
I can produce the effective relief for which I am intended. pj 

Amid all this controversy, I ask you to reflect on and re-examine 
my merits. Think back on the patients in your practice who have been 
helped through your clinical counseling and prudent prescriptions for me. 
Consider your patients with heart problems, G.I. problems, and inter- 
personal problems who, when their anxiety was severe, have been able 
to benefit from the medication choice you've made. Recall how often 
you Ve heard, as a result, "Doctor, I don't know what I would have done 
without your help. " 

You and I can feel proud of what we've done together to reduce 
excessive anxiety and thus help patients to cope more successfiily. 

If you examine and evaluate me in the light of your own experience, 
you'll come away with a confirmation of your knowledge that lama safe 
and effective drug when prescribed judiciously and used wisely. 

For a brief summary of product information on Valium (dazepam/ 
Roche) (g , please see the following page. Valium is available as 2-mg, 
5-mg and 10-mg scored tablets. 






Valium® 

diazepam/Roche 



Before prescribing, please consult complete 
product Information, a summary of which follows: 
Indications: Managemeni o* anxiely disorders, or 
shorl-term relief of symptoms of anxiety, symptomatic 
relief of acute agitation, tremor, delirium tremens and 
hallucinosis due to acute alcohol withdrawal, adjunc- 
tively in skeletal muscle spasm due to reflex spasm 
to local pathology, spasticity caused by upper motor 
neuron disorders, athetosis, stiff-man syndrome, 
convulsive disorders (not for sole therapy) 
The effectiveness of Valium {diazepam/Roche} tn long- 
term use, that is. more than 4 months, has not been 
assessed by systematic clinical studies The physician 
should periodically reassess Ihe usefulness of the drug 
for Ihe individual patient 

Contraindicated: Known hypersensitivity to the drug 
Children under 6 months of age Acute narrow angle 
glaucoma, may be used m patients with open angle 
glaucoma who are receiving appropriate therapy 
Warnings: Not of value in psychotic patients Caution 
against hazardous occupations requiring complete 
mental alertness When used ad|unctively m convulsive 
disorders, possibility of increase in frequency and/or 
severity of grand mal seizures may require increased 
dosage of standard anticonvulsant medication, abrupt 
withdrawal may be associated with temporary increase 
in frequency and/or severity of seizures Advise against 
simultaneous ingestion of alcohol and other CNS de- 
pressants Withdrawal symptoms similar to those with 
barbiturates and alcohol have been observed with 
abrupt discontinuation, usually limited to extended use 
and excessive doses Infrequently, milder withdrawal 
symptoms have been reported following abrupt discon- 
tinuation of benzodiazepines after continuous use, 
generally at higher therapeutic levels, for at least 
several months After extended therapy, gradually 
taper dosage Keep addiction-prone individuals under 
careful surveillance because of their predisposition to 
habituation and dependence 

Usage in Pregnancy: Use of minor tranquil- 
izers during first trimester should almost 
always be avoided because of increased 
risk of congenital malformations as sug- 
gested In several studies. Consider 
possibility of pregnancy when instituting 
therapy; advise patients to discuss therapy 
if they intend to or do become pregnant. 
Precautions: it combined with other psychotropics or 
anticonvulsants, consider carefully pharmacology of 
agents employed, drugs such as phenothiazines, 
narcotics, barbiturates, MAO inhibitors and other anti- 
depressants may potentiate its action Usual precau- 
tions indicated m patients severely depressed, or with 
latent depression, or with suicidal tendencies Observe 
usual precautions m impaired renal or hepatic function 
Limit dosage to smallest effective amount in elderly 
and debilitated to preclude ataxia or oversedation. 
Side Effects: Drowsiness, confusion, diplopia, 
hypotension, changes in libido, nausea, fatigue, 
depression, dysarthria, jaundice, skin rash, ataxia, 
constipation, headache, incontinence, changes m 
salivation, slurred speech, tremor, vertigo, urinary 
retention, blurred vision Paradoxical reactions such as 
acute hyperexciied states, anxiety, hallucinations, 
increased muscle spasticity, insomnia, rage, sleep 
disturbances, stimulation have been reported, should 
these occur, discontinue drug isolated reports of 
neutropenia, laundice, periodic blood counts and liver 
function tests advisable during long-term therapy 
Dosage: Individualize for maximum beneficial effect 
Adults Anxiely disorders, symptoms of anxiety, 2 to 10 
mg bid to q I d , alcoholism, 10 mg t i d or q i d in 
first 24 hours, then 5 mg t i d or q i d as needed, 
adjunctively m skeletal muscle spasm, 2 to 10 mg t i d 
or q I d : ad|unctively m convulsive disorders, 2 to 10 
mg b I d to q i d Genatnc or debilitated patients 2 to 
2V2 mg, 1 or 2 times daily initially, increasing as 
needed and tolerated (See Precautions ) Children i to 
2y2 mg t I d or q i d initially, increasing as needed 
and tolerated (not for use under 6 months) 
Supplied: Valiums (diazepam/Roche) Tablets, 2 mg, 
5 mg and 10 mg— bottles of 100 and 500, Tel-E-Dose^ 
packages of 100, available m trays of 4 reverse-num- 
bered boxes of 25. and in boxes containing 10 strips 
of 10. Prescription Paks of 50, available m trays of 10 



V Roc 

ROCHE > D)vi 

y Null 



Roche Laboratories 
ROCHE ^ Division of Hotfmann-La Roche Inc. 
jtley, New Jersey 071 10 



NORTH CAROLINA 
MEDICAL SOCIETY 
MEETINGS 




UN 
AHEAD 



COMMIHEE CONCLAVE 
September 23-27, 1981 

Mid Pines Club 
Southern Pines, N.C. 



ANNUAL MEETING 

May 6-9, 1982 

Pinehurst Hotel 
Pinehurst, N.C. 



August 1981, Vol. 42, No. 8 



NORTH CAROLINA MEDICAL JOURNAL 

Published Monthly as the Official Organ of The North Carolina Medical Society (lSSN-0029-2559) 



STAFF 

John H. Felts, M.D. 
Winston-Salem 

EDITOR 

Mr. William N. Milliard 
Raleigh 

BUSINESS MANAGER 



EDITORIAL BOARD 

Charles W. Styron, M.D. 
Raleigh 

CHAIRMAN 

George Johnson, Jr.. M.D. 
Chapel Hill 

Edwin W, Monroe, M.D. 
Greenville 

Robert W. Prichard, M.D. 
Winston-Salem 

Rose Fully. M.D. 
Kinston 

Louis Shaffner, M.D. 
Winston-Salem 

Jay Arena, M.D. 
Durham 

Jack Hughes, M.D. 
Durham 



The appearance of an advertisement in this publication does not 
constitute any endorsement of the subject or claims of the 
advertisements. 

The Society is not to be considered as endorsing the views and 
opinions advanced by authors of papers delivered at the Annual 
Meeting or published in the official publication of the Society. 
— Constitution and Byla\vs of the North Carolina Medical 
Society, Chapter IV. Section 4, page 4. 

NORTH CAROLINA MEDICAL JOURNAL, 300 S. Haw- 
thorne Rd., Winston-Salem, N.C. 27103, is owned and pub- 
lished by The North Carolina Medical Society under the direc- 
tion of its Editorial Board. Copyright' The North Carolina 
Medical Society 1981. Address manuscripts and communica- 
tions regarding editorial matter to this Winston-Salem address. 
Questions relating to subscription rates, advertising, etc.. 
should be addressed to the Business Manager. Box 27167, 
Raleigh, N.C. 27611. All advertisements are accepted subject 
to the approval of a screening committee of the State Medical 
Journal Advertising Bureau, 711 South Blvd., Oak Park, 
Illinois 60302 and/or by a Committee of the Editorial Board of 
the North Carolina Medical Journal in respect to strictly local 
advertising. Instructions to authors appear in the January and 
July issues. Annual Subscription. $12.00, Single copies, $2.00. 
Publication office: Edwards & Broughton Co., P.O. Box 27286, 
Raleigh. N.C. 27611. Second-class postage paid at Raleigh. 
North Carolina 27611 . 





Winchester Surgical Supply Company 

200 South Torrence-St. Charlotte, N.C. 28204 
Phone No. 704-372-2240 
MEDICAL SUPPLY DIVISION FOR YOUR PATIENTS AT HOME 
1500 E. THIRD STREET Phone No. 704/332-1217 

Winchester-Ritch Surgical Company 

421 West Smith St. Greensboro, N.C. 27401 
Phone No. 919-273-5581 

Serving the MEDICAL PROFESSION of NORTH CAROUNA 
and SOUTH CAROUNA lince 1919. 

We equip many new Doctors beginning practice each year, and invite your inquiries. 

Our salesmen are located in all parts of North Carolina 

We have DISPLAYED at every N.C. State Medical Society Meeting since 1921, and advertised 
CONTINUOUSLY in the N.C. Journal since January 1940 issue. 




works well in your office . . . 

NEOSPORIN Ointment 

(pofymyxin B-bacitracin-neomycin) 

Each gram contains: Aerosporin* (Polym>'xin B Sulfate! 5.000 units, bacitracin zinc 400 units, neomycin sulfate 5 mg 
(equivalent to 3.5 mg neomycin base); special white petrolatum qs; in tubes of 1 oz and 1/2 oz and 1/32 oz (approx.) foil packets. 

works just as well in their homes. 



It's effective therapy for 
.brasions. lacerations, open 
rounds, prlmaty pyodermas 
econdarily infected 
lermatoses. 

' It provides broad-spectrum 
iverlapping antibacterial 
tffectiveness against common 
■usceptible pathogens. 
Deluding staph and strep. 




• It helps prevent topical 

infections, and treats those that 

have already started. 



• It contains 

three antibiotics 

that are 

rarely used 

systemically. 

• It is convenient to 

recommend without a 

prescription. 



NEOSPORIN Ointment— for the office, for the home. 

(polym\'Xin B-bacitracin-neomycin) 

Effective • Economical • Convenient • Recommendable 



1 gram contains: Aerosporin® (Polymyxin B Sulfate) 
units, bacitracin zinc 400 units, neomycin sulfate 
^(equivalent to 3 5 mg neomycin base): special white 
datum qs: in tubes of 1 oz and 1/2 oz and 1 /32 oz 
Tox.) foil packets. 

lUVING: EJecause of the potential hazard of nephro- 
< city and ototoxicit\'due to neomycin, care should be 
" cisedwhen using this product in treating extensive 
I ns. trophic ulceration and otherextenslve conditions 
I re absorption of neomycin is possible. In bums 
' re more than 20 percent of the body surface is 
.ij-ted. especially if the patient has impaired renal 
'-lion or is receiving other aminoglycoside anti- 
j ics concurrently, not more than one application a 
Ijis recommended. 



When using neomycin-containing products to control 
secondary' infection in the chronic dermatoses, it 
should be borne in mind that the skin is more liable 
to become sensitized to many substances. Including 
neomycin- The manifestation of sensitization to 
neomycin is usually a lowgrade reddening with swelling. 
drv scaling and itching; it may be manifest simply as a 
failure to heal. During long-term use of neomycin- 
containing products, periodic examination for such 
signs is ad\1sable and the patient should be told to 
discontinue the product if the\' are obsen'ed. These 
svmptoms regress quickh' on withdrawing the medica- 
tion. Neomvcin-contalning applications should be 
avoided for that patient thereafter. 



PRECAUTIONS: As with other antibacterial prepara- 
tions, prolonged use may result in overgrowth of non- 
susceptible organisms, including fungi. Appropriate 
measures shoLud be taken if this occurs- 
ADVERSE REACTIONS: Neomycin is a not un- 
common cutaneous sensitizer. Articles in the current 
literature indicate an increase in the prevalence of 
persons allergic to neomycin. Ototoxicity and nephro- 
toxicit>' have been reported (see Warning section). 
Complete literature available on request from Profes- 
sional Services Dept PML 

i^ / Burroughs Wellcome Co. 

^^\ / Research Triangle Park 
Wellcome / North Carolina 27709 



5 Medical ^ 
q. Mutual ftj 



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Since then we have constantly improved our product, service and financial integrity. We also have 
expanded our program to offer all lines of insurance through our subsidiary Medical Insurance Agency Inc 
The agency specializes in serving the medical community with a variety of ever improving quality products 
designed specifically for your needs. 



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COMPANY 

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PHONES: Raleigh 828-9334 or Statewide 1-800-662-7917 



a 
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think they doif t need a computer. 




muse they think a computer is 
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• Improved staff efficiency 

'ecause they think they already 
ave firm control of their billing. 

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matically processes billing 
paperwork 

• Patient statements 

• Third party claims 

• Collection letters 

ecause they think they have 
isy access to vital practice data. 

The Sequoia Medical System 
arovides information immediately: 

• Aged receivable reports 
Procedure and diagnosis analysis 



• Daily production and revenue 
analysis 

• On-line access to AVi million 
medical journal articles in the 
National Library of Medicine 

• And many other types of 
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Because they think a computer is 
administratively disruptive. 

The Sequoia Medical System is 
designed to blend smoothly into 
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• Easy to use 

• Pre-programmed, turn-key system 



• Includes training, installation, 
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Because they haven't seen a 
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Sequoia can provide more time for 
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it's taking care of business . . . you're 
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Start looking into the benefits of a 
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1100 Larkspur Landing Circle, Larlsspur, CA 94939 

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MANDALA CENTER HOSPITAL 

From time to time individuals may experience extreme problems in living. When ttiis happens, it may 
become necessary to seek help from experienced members of the medical and helping professions. 
Mandala Center is an uncommon program dedicated to bringing to individuals an awareness of the 
source of their distress and help them find resolutions to their problems. 

Mandala Center is a JCAH accredited, private psychiatric hospital that specializes in the treatment of 
psychiatric illness, drug addiction, and alcoholism. The hospital was established in 1972 and is 
founded upon an interdisciplinary treatment approach. The 75-bed facility is located in Winston- 
Salem, NC, on a 15-acre site, and offers a full range of therapeutic modalities. Under medical 
supervision, the treatment team consists of psychiatrists, psychologists, pastoral counselors, social 
workers, psychiatric nurses, mental health workers and activities therapists. General medical care and 
special medical problems are provided for by the consulting staff. 

Adults and adolescents may enter the program which handles all categories of emotional and 
mental dysfunction. 




MEDICAL STAFF 

Bruce W Rau, M D.. Medical Director 

Roger L, McCauley, M.D. 

Larry T, Burch. M.D. 

Edward H. Weaver, M.D. 

Robert W. Gibson, M.D. 

James Mattox, M.D. 

All Jarrahi, M.D. 

Selwyn Rose, M.D. 

Glenn N. Burgess, M.D. 



MANDALA CENTER, INC. 

3637 Old Vineyard Road 

Winston-Salem, N.C. 27104 

(919) 768-7710 



MEMBERSHIP IN: 

N.C, Hospital Association 
National Association of Private 

Psyctiiatric Hospitals 
Blue Cross Contracting Hospital 

Medicare, Medicaid approved 



For Information, please contact: 
Richard V. Woodard. Administrator 



To»/ards Wholeness 



Will an apple a day keep the doctor away? 




Apples alone won't do it. 
Good nutrition is an impor- 
tant part of staying healthy, 
but even a well-balanced diet 
can't guarantee that an unexpected 
accident or sickness won't happen to you. 
You can help keep your financial picture 
healthy by planning ahead for a time when 
you may be disabled and your income is 
disrupted. 

As a member of the North Carolina Medical 
Society, you are eligible to apply for Disability 
Income Protection for younger doctors. This 
plan can provide you with a regular monthly 
benefit when a covered sickness or injury 
keeps you from your practice. You can use 
your benefits any way you choose — to buy 
groceries, make house or car payments or 



provide for your children's 
education. 

If you' re under the age of 55 and 
are active full time in your practice, 
simply fill out the coupon below and retum 
it today. Mutual of Omaha, underwriter of 
this plan, will provide personal, courteous 
service in furnishing full details of coverage. 
Of course, there's no obligation. 



Mutual of Omaha Insurance Company 

Mutual of Omaha Plaza 
Omaha, Nebraska 68175 

Please provide me complete information on the Disability 
Income Protection Plan available to members of the 
North Carolina Medical Society who are under age 55. 



Name 



Address . 
City 



_ State 



.ZIP 



Mutual 
^maha 




People ijou can count on... 

Life Insurance Affiliate: United of Omaha 

Mutual of Omaha Insurance Company 

Home Office: Omaha, Nebraska 



REFERRING YOUR PATIENTS 

FOR SPECIAL TREATMENT TO 

DURHAM — THE CITY OF MEDICINE 



Duke Medical Center 
V.A. Hospital 



lAMAD 

INN ' 



Durham County General 
McPherson's Hospital 



We are convenient to Duke Medical Center, V.A. Hospital and McPherson's Hospital. We 
offer free transportation to the hospitals every hour between the hours of 8:00 a.m. and 
6:00 p.m. Tra^isportation after 6:00 p .m. by special request only . Via our free van service , 
we are only 7 to 8 minutes away and your parking problems are solved. 

We offer friendly , courteous service to all our guests. So ofteii the special needs of patients 
and their families might be overlooked. We pride ourselves on our reputation for caring 
about the individuals who make the Ramada Inn Downtown their temporary home during 
their stay in Durham. 



159 tastefully decorated rooms 

Indoor heated pool 

Sauna 

Exercise room 

Whirlpool 

New Zenith Color T.V. with cablevision 

A.M.-F.M. stereo radio 

All rooms entered from inside corridor 



Lounge 

Full service restaurant 

Handicap rooms 

10% discoun'. after 30 days 

Nightly security 

Washer and dryer 

Refrigerators available 

Efficiencies available 



We hope that when making appointments for your patients needing local accommoda- 
tions, that you will remember us at the Ramada Inn Downtown. 



For Reservations Call 
919-683-1531 



RAMADA INN DOWNTOWN 



1-40 & Duke Street 

P. O. Box 98 
Durham, N.C. 27702 



hwi/o data show 







i^ 



® 



^ith greater acid-neutralizing capacity, 

Ncolln 

^ets relief into 
circulation 
aster than 
\scriptin" A/D 



"hen salicylate blood levels of NEOLIN and 
.scriptin A/D were compared in three separate 
ossover studies, total amounts were found to be 
gher for NEOLIN up to one hour after ingestion, 
''olunteers took 2 five-grain tablets of either 
ledication.) More rapid absorption with NEOLIN 
leans more rapid availability for pain relief, par- 
•;ularly important to patients with osteoarthritis. 




Ncolinthe 



41 



^ 



'^/^ 



^^ 



^ 



^ 




^ 
i^ 



jr 







To 

60 
50 
40 
30 
20 
10 



tal Salicylate mcg/ml plasma 

Neolin 

Ascriptin A/D •™°»" 


STUDY 1(30 Subjects) 




rime 10 mm 20 mm. 40 mm 60 mm | 



Total Salicylate mcg/ml plasma STUDY II (40 Subjects) 

Neolin 

Ascriptin A/D '-~~ 



Time lOn 



Total Salicylate mcg/ml plasma 

Neolin 

Ascriptin A/D """"^ 



STUDY III (29 Subjects) 




aspirin for today— and every day 



Each capsule-shaped, scored tablet contains 324 mg 
aspirin, 225 mg magnesium carbonate and 200 mg 
calcium carbonate. 



(£1 1981 Bristol-Myers Company 



In vitro data show 



/ 



nnnnnnr 



r 



Neolin 

Each tablet contains 324 mg aspirin, 225 mg magnesium 
carbonate and 200 mg calcium carbonate. 

has greater 
acid-neutralizing 
effectiveness than 
AscriptinWD 

NEOLIN contains two proven effective acid- 
neutralizers, magnesium carbonate and calcium 
carbonate. 

Ascriptin A/D, on the other hand, is formulated 
with magnesium hydroxide and aluminum hydroxide. 
Aluminum hydroxide has been reported to be a 
poorly effective acid-neutralizer.^ Additionally, 
drying of this particular buffer, as must be done 
for tablet use, alters its structure, further reducing 
antacid efficacy.^ 



It is not suprising, therefore, that NEOLIN proved superior 
to Ascriptin A/D in two separate in vitro tests* designed t 
evaluate the acid-neutralizing capacity of buffered aspirin. 
These studies showed that NEOLIN had 1 7.2% to 48.2°/c 
greater acid-neutralizing capacity than did Ascriptin A/D. 



Test I 



Total Acid-Neutralizing Capacity (mEq) 



Neolin 



16.9 



Ascriptin A/D 



11.4 



Test II Total Acid-Neutralizing Capacity (mEq) 



Neolin 



17.0 



Ascriptin A/D 



14.5 



1 . Harvey, S.C: "Gastric antacids and digestants," In Goodman, L.S. 

and Gllman, A. (eds): Pharmaceutical Basis of Therapeutics, The, 

ed 6, New York: Macmillan Publishing Co., Inc., 1980, p 991. 
2. Garnett, W.R.: "Antacids," in Apple, W. (ed): Handbool< of 

Nonprescription Drugs, ed 6, Washington, D.C.: American 

Pharmaceutical Association, 1979, p 6. 

* Bristol-Myers Test Method designed to evaluate the acid- 
neutralizing capacity of buffered aspirin preparations using single 
tablet samples of NEOLIN and Ascriptin A/D. Each product stirred 
for 1 5 minutes in an excess of 0. 1 N HCI at 25 °C (Test I) and 
37 °C (Test II) and back titrated with NaOH to pH 2.8. 



BRISTOL-MYERS 



W 



PROFESSIONAL PRODUCTS 




PRESIDENT'S NEWSLETTER 

NORTH CAROLINA MEDICAL SOCIETY 



NO. 3 



AUGUST 1581 



Dear Colleagues: 

As the old folks used to say: "I take pen in hand to tell you" that the North 
Carolina Medical Society must muster all possible strength toward developing real 
clout with the North Carolina Legislature. Since the Legislature convened in 
January 1981, I have almost made the Legislative Building my home and have read 
three newspapers daily. I, as well as others who have been there since January, 
am shocked at our lack of success with several major issues which will impact health 
care and the practice of medicine tremendously. By this time, you probably know 
that we were unsuccessful in our attempt to repeal the Optometric Drug Use Statute. 
Our ophthalmology colleagues have worked long and hard for this cause but to no 
avail. Their Repeal Bill was stashed in a subcommittee — never to see the light of 
day during this session. Those Legislators can surely know that we will be back — 
again and again — until that bill is repealed. 

The Chiropractic Bill, to redefine the practice of Chiropractic, was substantially 
amended by the State Senate. After Senate passage, the amended bill was referred 
to a subcommittee of the House Health Committee where extensive testimony was heard 
from a variety of organizations, including the Medical Society. The subcommittee 
rewrote the bill into a proposed committee substitute. The committee substitute 
was adopted by the full House Health Committee. Unfortunately, the full committee, 
rather than give the committee substitute a favorable report, referred both the 
substitute and the original bill back to subcommittee where both will be considered 
during the 1982 Short Session of the General Assembly. While this does not con- 
stitute a defeat for the North Carolina Medical Society, we certainly cannot think 
of it as a victory. Colleagues, it is time for us to gather and re-group for the 
next round. PLEASE try to attend our Legislative Symposium at Myrtle Beach, 
October 30, 31, and November 1. We need your ideas and support. If we are to suc- 
ceed, we need the active involvement of every member! 

The membership of the North Carolina Medical Society IS the Society. A primary goal 
of this administration must be a major increase in our membership. Although the 
North Carolina Board of Medical Examiners assures us that there are 8,300 registered 
physicians with North Carolina addresses, the Society can boast of only 5,700 members, 
of which only 5,100 are full dues paying members. Consequently, some 3,000 physi- 
cians should be added to our membership. John W. Foust, M.D., First Vice-President 
and Chairman of Membership, is mounting a tremendous, energetic membership campaign 
which should continue through the years. John has already contacted all County Society 
Presidents, District Councilors, and Section Chairmen for information on known 
1 non-members . Please respond as quickly as possible in order that we may be prepared 
[for an extensive membership drive in October and November. John, with the able assis- 
j tance of Membership Secretary, Deanna Godwin, has worked tirelessly on this cam- 
paign and deserves the total cooperation of every one of us. 

Sarah T. Morrow, M.D., Secretary, North Carolina Department of Human Resources, and 
Barbara D. Matula, Director, North Carolina Division of Medical Assistance, noti- 
fied the North Carolina Medical Society that the Administration still has no know- 
ledge as to the specific actions to be taken by Congress in regard to the Medicaid 
Program. For the past several months, Mrs. Matula has studied all of the options 
North Carolina may be forced to take in the face of a markedly reduced Medicaid 



budget. She invited four (4) representatives of each of the major health professional 
associations to meet with her to discuss these options on Wednesday, July 22, 1981. 
She stated that the options are "wide ranging and of varying degrees of severity". 
Representatives attending from the North Carolina Medical Society were Don Chaplin 
(Chairman, Committee on Legislation), John McCain (Chairman, Public Affairs 
Commission), Joe Russell (Chairman, Committee on Social Services Programs), and 
myself. We were told that Congress is now considering proposals which could result 
in a loss, to the North Carolina Medicaid Program, of from $37 million to $94 million, 
dependent on the adoption of one or more bills. Dr. Sarah T. Morrow and Mrs. Matula 
asked for the input of the major health professional organizations in choosing options. 
Because the State does not have the revenue in the State Budget to pickup the loss 
of these Federal dollars, the Medicaid Budget will be cut . Some of the options shown 
to us are: 

1. Reduction of the number of recipients by elimination of coverage to the 
"medically needy" (Legislature seems to oppose) 

2. Targeting services (Services of a limited nature to a specific group) 

3. Limitations or elimination of some optional services 

4. Co-payments on all services (North Carolina is now in the maximum of the 
Federal allowable co-payment range) 

5. Family supplementation (Requirement that families contribute to the care 
of long-term care patients) 

6. Hospital Day Limit 

7. Physician Visit Limit 

8. Prescription Limit 

9. Drug Formulary 

10. Limitation on the number of Long Term Care beds 

11. Prior approval on all elective surgery 

12. Lower or freeze reimbursement rates 



13. Limitation of dental services 

The above may not be a complete list but, at least, makes us aware that the problem 
is urgent. I'm afraid that the professional health organizations were of little 
assistance. If you have ideas as to how these cuts can be made in a manner which 
would be fair and equitable to providers, recipients, and taxpayers , please contact 
me immediately. Rest assured that I shall pass it on to those who must make the 
cuts. Early replies will allow us to incorporate your ideas into the response now 
being prepared. 

On re-reading this despondent newsletter, I promise that the next one will be more 
cheerful. After all, the Legislature has gone home! Onward and upward! 



My best to you and your family. 




»1 



Josepl^ne E. Newell, M.D. 
President 




Equagesic'' 

[meprobamate and ethoheptazine citrate with aspirin) Wyeth 

fwofold analgesic action teamed with time-proven efficacy against 
:oncurrent anxiety and tension in patients with musculoskeletal disease* 



3UAGE5IC— Abbreviated Summary 



I'INDICATIONS; Based on a review of Ihis drug dy Ihe 
National Academy gI Sciences— National Research 
Counal and or other inlormation. FDA has classified 
the indications as (oilows 

Possibly' elective lor the treatmeni of pain accom- 
oanied By tension ana or anxiety in patients wilh mus- 
cuioshetelai disease or tension headache 
Final classification o' the less-lhan-effective indications 
requires turthei investigation 

The effectiveness ot Equagesic in long-term use, i e 
more than toui months has not been assessed by sys* 
lematic clinical studies The physician should penodi- 
cally leassess usefulness of the drug lor the individual 



JNTHAINOICATIONS: Equagesic should not be given to 
lividuals with a history of sensitivity o' severe intolerance 
aspinn meprobamate. or ethoheptazine citrate 
ARNINGS: Careful supervision of dose and amounts pre- 
■ibeO for patients is advised, especially v/ilh those patients 
h known propensity lor taking excessive quantities o' dnjgs 
cessive and prolonged use in susceptible persons, eg . 
»holics. lormer addicts and other severe psychoneurot- 
, has been reported lo 'esull in dependence on or habil- 
twn (0 the drug Where excessive dosage has continued 

weeks or rrronths dosage should be reduced gradually 
*ier than abruptly stopped, since withdrawal of a "crutch" 
ly precipitate withdrawal reaction of greater pioporlions 
■rt that tor which the drug was originally prescribed Abrupt 
continuance ot doses m excess of the recommended dose 

resulted m some cases in the occurrence of epileptiform 
zures 

eaal care should be taken to warn patients laktng mepio- 
Tiale thai tolerance to alcohol may be lowered wilh resull- 

slowing of reaction time and impairment o' judgment and 
Jrdi nation 

AGE tN PREGNANCY AND LACTATION: An increased 

^ ot congenital maltormations associated with the use 



of minor tranquilizers (meprobamate. chlordiazepomde. 
and diazepam) during the lirst trimester of pregnancy 
has been suggested m several studies Because use ot 

these drugs is rarely a matter of urgency, Iheir use dur- 
ing this pericx] should almost always be avoided The 
possibility that a woman of child-bearing potential may 
be pregnant at the lime ot institution of therapy should 
be considered Patients should be advised that if they 
become pregnant during therapy or intend to become 
pregnant they should communicate with Iheir physi- 
cians about Ihe desirability ot discontinuing the drug 
Meprobamate passes Ihe placental barrier It is present 
both in umbilical-cord blood at or near maternal plasma 
levels and in breast milk of lactating mothers at concen- 
trations two to four times that of maternal plasma When 
use of meprobamate is contemplated m breast-feeding 
patients, the drug's higher concentration in breast mitk 
as compared lo maternal plasma levels should be 
considered 

PreparaHons containing aspinn should be kept out of the 
reach of children Equagesic is not recommended for pa- 
tients 12 years of age and under 

PRECAUTIONS: Should drowsiness, ataxia, or visual distur- 
bance occur Ihe dose should be reduced II symptoms con- 
tinue, patients should not operate a motor vehicle or any 
dangerous machinery 

Suicidal attempts wiih meprobamate have resulted m coma, 
shock vasomotor and respiratory collapse, and anuna Very 
few suiadal atlempts were fatal although some patients in- 
gested very large amounts ot the drug ;20 to 40 gm] These 
doses are much greater than recommended The dmg should 
be given cautiously, and m small amounts, to patients who 
have suicidal tendencies In cases where excessive doses 
have been taken sleep ensues raprdly and blood pressure 
piulse. and respiratory rates are reduced to basal levels Hy- 
perventilation has been reported occasionally Any drug re- 
maining in the stomach should be removed and symptomatic 
treatment given Should respiration become very shallow and 
skiw CNS stimulants eg . caffeine MeHazol. or ampheta- 



mine, may be cautiously administered It severe hypotension 
develops, pressor amines should be used parenterally to re- 
store blood pressure to normal levels 

ADVERSE REACTIONS: A small percentage of patients 
may expenence nausea with or without vomiting and epigas- 
iric distress Dizziness occurs rarely when meprobamate and 
ethoheptazine alrale with aspinn is administered in recom- 
mended dosage The meprobamate may cause drowsiness 
but. as a rule this disappears as therapy is continued Should 
drowsiness persist and be associated with ataxia this symp- 
tom can usually be controlled by decreasing the dose, but 
occasionally it may be desnable to administer central stimu- 
lants such as amphetamine or mephentermine sulfate con- 
comitantly lo control drowsiness 

A clearly related side effect lo the administration of mepro- 
bamate IS Ihe rare occurrence of allergic or idiosyncratic re- 
actions This response develops, as a rule m patients who 
have had only 1-4 doses of meprobamate and have not had 
a previous contact with the drug Previous history ol allergy 
may or may not be related to the incidence ot reactions 
Mild reactions are chaiadenzed by an itchy urticarial or ery- 
thematous, maculopapular rash which may be generalized 
or confined to the groin Acute nonthrombocytopenic purpura 
with cutaneous petechiae ecchymoses. penpheial edema 
and lever have also been reported 

More severe cases, observed only very rarefy, may also have 
other allergic responses, including lever, fainting spells an- 
gioneurotic edema, bronchial spasms, hypotensive cnses (1 
fatal easel, anaphylaxis, stomatitis and proctitis (1 case), and 
hyperthermia Treatment should be symptomatic such as 
administration of epinephrine, antihistamine, and possibly 
hydrocoriisone Meprobamate should be stopped, and rein- 
stitution ol therapy should not tie attempted 
Rare cases have been reported where patients receiving me- 
probamate suffered irom aplastic anemia |1 fatal case] 
thromlxK/topenic purpura, agianulocylosis and hemolytic 
anemia In nearly every instance reported, other toxic agents 
knowm to have caused these conditions have been associ- 
ated with meprobamate A few cases of leukopenia during 



continuous ad mi net ration of meprobamate are reported, most 
ol these returned to normal without discontinuation ol the 
drug 

Impairment ot accommodation and visual acuity has been 
reported rarely 

OVERDOSE: Two instances of accidental or intentional sig- 
nificant overdosage with ethoheptazine citrate combined with 
aspirin have been reported These were ac«)mpanied by 
symptoms ot CNS depression including drowsiness and light- 
headedness, with uneventful recovery However on Ihe basis 
of pharmacological data it may be anticipated thai CNS stim- 
ulation could occur Other aniiopated symptoms would in- 
clude nausea and vomiting Appiopnate theiapy 0' signs antj 
symptoms as they appear is the only recommendation pos- 
sible at this time Overdosage with ethoheptazine combined 
with aspirin would probably produce the usual symptoms and 
signs of salicylate intoxication Observation and treatment 
should include induced vomiting or gastric lavage specific 
parenteral electrolyte therapy for ketoacidosis and dehydra- 
tion watching for evidence of hemorrhagic manifestations 
due to hypoprothrombinemia which, if it occurs, usually re- 
quires whole-blood transfusions 

DESCRIPTION: Each Equagesic tablet contains 150 mg me- 
probamate. 75 mg ethoheptazine citrate and 250 mg aspinn 

Copyright c igsi. Wyeth Laboratories 
Ail rights reserved 

'This drug has been evaluated as possibly 
effective lor Ihis indication 

Wyeth Laboratories 

•* ' Philadelphia, PA 19101 



\AA 




step 



for mild to moderate pain 

Wygesic® 

(65 mg propoxyphene HCI and 650 mg acetaminophen) Wyeth 



More than twice as much acetaminophen as the leading combination plus a full 
therapeutic dose of propoxyphene... all in a convenient, economical single tablet. 



WYGESIC— Abbreviated Summary 

INDICATION '-.- :ne relief o' mild-io-moderate pain 
CONTRAINDICATION; Hypersensilivily lo piopox- 
■ip-! ■ •- ' .1 f'.itiiinophen 

WARNINGS; Ct-iS ADDITIVE EFFECTS AND OVER- 
DOSAGE Propoxyphene in combmaiion wilh alcohol 
tranquilizers, sedative-hypnolics or olher CNS de- 
pressants has an additive depressant edeci Pa- 
iienis taking ihis drug should De advised ot the additive 
effect and warned not to exceed the dosage recom- 
mended To!(ic effects and fatalities have occurred 
loMowing overdoses of propoxyphene alone or m 
CD.Tibinalion with other CNS depressants IVlosi ot 
these patients had hislones oi emotional disturb- 
ances or suicidal ideation or attempts, as well as 
misuse of tranquilizers, alcohol, or other (JNS-active 
drugs Caulion should be exercised m prescribing 
large amounts ol propoxyphene for such patients 
isee Management o( Overdosage) 
DRUG DEPENDENCE; Propoxyphene can produce 
drug dependence characterized by psychic depend- 
ence and less trequenlly, physical dependence and 
tolerance It will only partially suppress the with- 
drawal syndrome m individuals physically dependent 
on morphine or other narcotics The abuse liability ol 
propoxyphene is qualitatively similar to codeines al- 
though quantitatively less, and propoxyphene should 
be prescribed with the same degree of caution ap- 
propriate to the use of codeine 

USAGE IN AMBULATORY PATIENTS; Propoxy- 
phene may impair the menial and/or physical abilities 
required for potentially hazardous tasks eg d'lvmg 
a car or operating machinery Patients should be 
cautioned accordingly 

USAGE IN PREGNANCY: Safe use m pregnancy 
has not been established relative to possible ad- 
verse eltects on letal development INSTANCES OF 
WITHDRAWAL SYMPTOI^S IN THE NEONATE 
HAVE BEEN REPORTED FOLLOWING USAGE 
DURING PREGNANCY Therefore propoxyphene 
should noi be used m pregnant women unless, m the 



judgement of the physician the potential benefits 
outweigh thie possible hazards 

USAGE IN CHILDREN: Propoxyphene is not rec- 
ommended tor Children because documented clinical 
experience has been insufficient to establish safety 
and a suitable dosage regimen m the pediatric group 
PRECAUTIONS: (Jonfusion. anxiety, and tremors 
have been reported m a tew patients receiving pro- 
poxyphene concomitantly with orphenadnne The CNS 
depressant effect of propoxyphene may be additive 
with other CNS depressants, including alcohol 
ADVERSE REACTIONS: The most frequent ad- 
verse reactions are dizziness sedation nausea and 
vomiting These seem more prominent m ambulatory 
than in nonambulatory patients some of these re- 
actions may be alleviated if the patient hes down 
Other adverse reactions include constipation, ab- 
dominal pam. skin rashes. Iight-headedness head- 
ache weakness, euphoria dysphoria, and mmor 
visual diSturtsances The chronic ingestion of propox- 
yphene m doses over 800 mg per day has caused 
toxic psychoses and convulsions Cases ol liver dys- 
function have been reported 

DRUG INTERACTIONS: Propoxyphene m combi- 
nation with alcohol, tranquilizers, sedative-hypnot- 
ics and other CNS depressants has an additive 
depressant effect Patients taking this drug should 
be advised of the additive effect and warned not to 
exceed the dosage recommended (see Warnings) 
Contusion anxiety and tremors have been reported 
in a few patients receiving propoxyphene concomi- 
tantly with orphenadnne 

MANAGEMENT OF OVERDOSAGE: SYt^PTOMS 
The manifestations of serious overdosage with pro- 
poxyphene are similar to those of narcotic overdos- 
age and include respiratory depression (a decrease 
in respiratory rale and or tidal volume. Cheyne- 
Stokes respiration, cyanosis), extreme somnolence 
progressing to stupor or coma, pupillary constriction, 
and circulatory collapse In addition lo these char- 
acteristics, which are reversed by narcotic antago- 



nists such as naloxone, there may be other effects 
Overdoses ol propoxyphene can cause delay of car- 
diac conduction as well as focal or generalized con- 
vulsions, a prominent feature m most cases of severe 
poisoning Cardiac arrhythmias and pLJimonary edema 
have occasionally been reported, and apnea, car- 
diac arrest and death have occurred 
Symptoms ol massive overdosage with acetamino- 
phen may include nausea, vomitmg anorexia, and 
abdominal pain beginning shortly after ingestion and 
lasting tor 12 lo 24 hours However, early recognition 
may be difdcult smce eany symptoms may be mild 
and nonspecific Evidence of hver damage is usually 
delayed After the initial symptoms, the patient may 
feel less ill. however laboratory determinations are 
likely to show a rapid rise in liver enzymes and bili- 
rubin In case of senous hepatotoxicity, jaundice, co- 
agulation defects, hypoglycemia, encephalopathy, 
coma, and death may follow Renal failure due to 
tubular necrosis, and myocardiopalhy, have also been 
reported 

Ingestion of 10 grams or more of acetaminophen 
may produce hepatotoxicity A 13-gram dose has re- 
portedly been fatal 

TREATMENT; Primary attention should be given to 
the reestablishment ol adequate respiratory ex- 
change through provision of a patent airway and in- 
stitution of assisted or controlled ventilation The 
narcotic antagonists, naloxone nalorphine and lev- 
allorphan are specific antidotes agamst the respira- 
tory depression produced by pr^opoxyphene An 
appropriate dose ot one of these antagonists should 
be administered prelerably IV .simultaneously with ef- 
forts at respiratory resuscitation and the antagonist 
should be repeated as necessary until the patient s 
condition remains satisfactory In addition lo a nai- 
cotic antagonist the patient may require careful titra- 
tion with an anticonvulsant to control seizures 
Analeptic drugs le g catfeme or amphetaminei should 
not be used because of iheir tendency to precipitate 
convulsions 



Oxygen IV fluids vasopressors and other suppor- 
tive measures should be used as indicated Gastric 
lavage may be helpful Activated charcoal can at)-; 
sorb a signilicant amount of ingested propoxyphene '■ 
OiaiyStS is of little value m poisonmg by propoxy' 
phene alone Acetaminophen is rapidly absorbed 
and efforts to remove the drug from the body shouiti 
not be delayed Copious gastnc lavage and or induc- 
tion of emesis may be indicated Activated charcoa 
is probably ineffective unless administered almos' 
immediately after acetaminophen ingestion Neilhei 
forced diuresis nor hemodialysis appears lo be ef 
fective in removing acetaminophen Since acetami- 
nophen m overdose may have an antidiuretic eflec 
and may produce renal damage administration o 
fluids should be carefully monitored lo avoid over 
load It has been reported that meicaplamme (cysl 
leamme) or other thiol compounds may protect agains| 
liver damage it given soon alter overdosage (8-lC; 
hours) N-acetylcysteine is under investigation as H 
less toxic alternative to mercaptamme, which ma;] 
cause anorexia, nausea, vomiting, and drowsiness; 
Appropriate literature should be consulted lor lurthe' 
inlormation (JAIWA 237 2406-2407. 1977) 
Clinical and laboratory evidence ol hepatotoxicity nia>j 
be delayed up to one week Acetaminophen plasm; 
levels and halMile may be useful m assessing Ihil 
likelihood of hepatotoxicity Serial hepatic enzyrrrj 
determinations are also recommended 

Copyright 4 1981. Wyeth Laboratories- 
All rights reserved. 

Wyeth Laboratories 

' ' Philadelphia, PA 19101 



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Graphic Cardiology provides prompt, professional 
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experience in scanning and cardiology. 

For more information and a free 

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ADDRESS . 
QTY 



. STATE ZIP CODE . 



L. 



ORGANIZATION. 






Officers 
1981-1982 

NORTH CAROLINA MEDICAL 
SOCIETY 



President Josephine E. Newell, M.D. 

Raleigh Townes, Apt. 47, 525 Wade Ave., Raleigh 27605 

President-Elecl Marshall S. Redding, M.D. 

1142 N. Road St., Elizabeth City 27909 

First Vice-President John W. Foust, M.D. 

3535 Randolph Rd., Charlotte 28222 

Second Vice-President Emery C. Miller, Jr., M.D. 

Bowman Gray, Winston-Salem 27103 

Secretary Jack Hughes, M.D. 

923 Broad St., Durham 27705 (1982) 

Speaker Henry J. Carr, Jr., M.D. 

603 Beaman St., Clinton 28328 

Vice-Speaker T. Reginald Harris, M.D. 

808 Schenck St., Shelby 28150 

Past-President Frank Sohmer, M.D. 

2240 Cloverdale Ave., Ste. 88, Winston-Salem 27103 

Executive Director William N. Milliard 

222 N. Person St., Raleigh 27611 

Councilors and Vice-Councilors — 1981-1982 

First District Robert E. Lane, M.D. 

Chowan Med. Ctr., Edenton 27932 (1983) 

Vice-Councilor James M. Watson, M.D. 

1134 N. Road St., Elizabeth City 27909 (1983) 

Second District Charles P. Nicholson, Jr.. M.D. 

3108 Arendell St., Morehead City 28557 (1982) 

Vice-Councilor Alfred L. Ferguson, M.D. 

6 Doctors Park. Stantonsburg Rd., Greenville 27834 (1982) 

Third District R. Bertram Williams, Jr., M.D. 

1414 Medical Center Dr., Wilmington 28401 (1982) 

Vice-Councilor Charles L. Garrett, Jr., M.D. 

P.O. Box 1358, Jacksonville 28540 (1982) 

Fourth District Robert H. Shackelford, M.D. 

238 Smith Chapel Rd., Mt. Olive 28365 (1983) 

Vice-Councilor Lawrence M. Cutchin. Jr., M.D. 

P.O. Box 40, Tarboro 27886 (1983) 

Fifth District Bruce B. Blackmon, M.D. 

P.O. Box 8, Buies Creek 27506 (1984) 

Vice-Councilor Giles L. Cloninger, Jr., 

115 Main St., Hamlet 28345 (1984) 

Sixth District W. Beverly Tucker, 

Ruin Creek Rd., Henderson 27536 (1983) 

Vice-Councilor C. Glenn Pickard, Jr. 

N.C. Memorial Hospital, Chapel Hill 27514 (1983) 

Seventh District James B. Greenwood, Jr. 

4101 Central Avenue, Charlotte 28205 (1984) 

Vice-Councilor Thomas L. Dulin, 

P.O. Box 220892, Charlotte 28222 (1984) 

Eighth District Shahane R. Taylor, Jr. 

348 N. Elm St.. Greensboro 27401 (1982) 

Vice-Councilor I. Gordon Early, M.D. 

2240 Cloverdale Ave.. Ste. 192. Winston-Salem 27103 (1982) 

Ninth District Jack C. Evans. M.D. 

244 Fairview Dr.. Lexington 27292 (1982) 

Vice-Councilor Benjamin W. Goodman. M.D. 

24 Second Ave.. N.E., Hickory 28601 (1982) 

Tenth District Charles T. McCullouoh. Jr.. M.D. 

Bone & Joint Clinic. Doctors Dr.. Asheville 28801 (1984) 

Vice-Councilor George W. Brown. M.D. 

102 Brown Ave.. Hazelwood 28738 (1984) 



M.D. 
M.D. 
M.D. 
M.D. 
M.D. 
M.D. 



Section Chairmen - 

Allergy & Clinical Immunology . . . 



1981-1982 



Anesthesiology J. LeRoy King. M.D. 

"3600 New Bern Ave.. Raleigh 27610 

Dermatology Charles E. Cummings. M.D. 

281 McDowell Street, Asheville 28803 

Emergency Medicine 

Family Practice Hal M. Stuart, M.D. 

180-C Parkwood Dr., Elkin 28621 

Internal Medicine William R. Bullock, M.D. 

217 Travis Avenue. Charlotte 28204 

Neurological Surgery Robert E. Price. Jr.. M.D. 

1830 Hillandale Rd.. Durham 27705 

Neurology & Psychiatry Assad Meymandi, M.D. 

1212 Walter Reed Road, Fayetteville 28304 

Nuclear Medicine William McCartney. M.D. 

N.C. Memorial Hosp.. Dept. of Nuclear Medicine. 
Chapel Hill 27514 

Obstetrics & Gynecoloi>y Talbot E. Parker. Jr.. M.D. 

2400 Wayne Memorial Drive, Ste. K, Goldsboro 27530 

Ophthalmology J. Lawrence Sippe, M.D. 

1350 S. Kings Drive, Charlotte 28207 

Orthopaedics Richard N. Wrenn. M.D. 

1822 Brunswick Avenue. Chariotte 28207 
Otolaryngology & Maxillofacial 

Surgery Walter R. Sabiston, M.D. 

400 Glenwood Ave., Kinston 28501 

Pathology Ron Edwards. M.D. 

3000 New Bern Ave.. Raleigh 27610 

Pediatrics DavidT. Tayloe. M.D. 

608 E. 12th St.. Washington 27889 
Plastic & Reconstructive 

Surgery Andrew W. Walker. M.D. 

2215 Randolph Rd.. Charlotte 28207 

Public Health & Education Verna Y. Barefoot. M.D. 

2504 Old Cherry Point Rd.. New Bern 28560 

Radiology Luther E. Barnhardt. Jr.. M.D. 

Executive Park. Ste. 203, Asheville 28801 

Surgery Carl A. Sardi. M.D. 

Climax 27233 

Urology Donald T. Lucey, M.D. 

P.O. Box 17908, Raleigh 27619 

Delegates to the American Medical Association 

James E. Davis, M.D., 2609 N. Duke St., Ste. 402, Durham 27704 

— 2-year term (January 1. 1981-December 31 . 1982) 
John Glasson. M.D.. 2609 N. Duke St.. Ste. 301 . Durham 27704 — 

2-year term (January 1. 1981-December 31. 1982) 
David G. Welton. M.D.. 3535 Randolph Rd.. 101-W. Charlotte 

28211 — 2-year term (January 1. 1980-December 31. 1981) 
Frank R. Reynolds. M.D.. 1613 Dock St., Wilmington 28401 — 

2-year term (January 1, 1981-December 31 , 1982) 
Louis deS. Shaffner, M.D.. Bowman Gray. Winston-Salem 

27103 — 2-year term (January 1, 1980-December 31. 1981) 

Alternates to the American Medical Association 

E. Harvey Estes. Jr.. M.D.. Duke Med. Ctr., Box 2914, Durham 
27710 — 2-year term (January 1, 1981-December 31, 1982) 

Charles W. Styron. M.D..615St. Mary's St.. Raleigh 27605 — 
2-year term (January 1. 1980-December 31, 1981) 

D. E. Ward, Jr., M.D., 2604 N. Elm St., Lumberton 28358 — 
2-year term (January 1, 1980-December 31 , 1981) 

Jesse Caldwell, Jr., M.D., 1307 Park Lane, Gastonia 28052 — 

2-year term (January 1, 1981-December 31, 1982) 
■rank Sohmer, M.D.. 2240 Cloverdale Ave.. Ste. 88. Winston- 
Salem 27103 — 2-year term (January 1. 1981-December31. 1982) 



534 



Vol. 42. No. 8 






WHEN YOU THINK OFaDISABIUTY— 

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Forced change in family life style! 
Even loss of your professional practice! 

THE PRESCRIBED TREATMENT olmin7iT- 

Full participation in your 
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REASON — the broadest coverage at the lowest premium scale — 

Recently reduced rates for members under age 50 by virtue of Society sponsorship and 

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Variety of options to meet either personal or corporate needs! 
No medical exam required nor restriction of benefit due to other coverage! 
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An added complication... 1 

in the treatment of bacterial bronchitis 




Bnel Summary 

Cnnsull me package lileralure lot prescnbmg 

information. 

Inilicalions anil Usage: Ceclor • (cefaclor, Lillyl is 

inrJicaled m me irealmenl of Itie followmg mleclions 

when caused by susceplibic strains of the designated 

microorganisms 

I nwprrpspiiatnrv mleclions . including pneumonia 
caused by Sirep/ococcus pneumoniae (Diplococcus 
pneumoniae). Haemophilus intluemae. and S 
pyooenes (group A betamemolyiic slreptococci) 
Aopropriate culture and susceplibilily studies 
should be peilormed to determine susceplibihty of 
me causative oigamsm to Ceclor 
Conlrainilicalion; Ceclor is contraindicated in patients 
with known allergy to the cephalnsponn group ol 
antibiotics 
Watnicigs: in penicillin-sensitive patients 

CEPHALOSPORIN ANTIBIOTICS SHOULD BE AOUINISTEnEO 
CAUTIOUSLT THERE IS CLINICAL AND LABORATORY 
EVIDENCE OE PARTIAL CROSS-ALLERGEN IC1TV OE THE 
PENICILLINS AND THE CEPHALOSPORINS. AND 1 HERE ARE 
INSTANCES IN WHICH PATIENTS HAVE HAD REACTIONS TO 
BOTH DRUG CLASSES (INCLUDING ANAPHYLAXIS ARER 
PARENTERAL USE) ^ . ^ 

Anlibiolics including CecloT should Be administered 
cautiously 10 any palient who has demonstrated some 
torm 01 allergy, particularly to drugs 
Precautions: II an allergic reaction to cetaclor occurs^ 
the drug should be discontinued, and, il necessary, the 
patient should be treated with appropriate agents^ e g 
pressor amines, antihistamines, or corlicosteroids 

Prolonged use otcelaclor may result in the 
overorowth ot nonsusceplible organisms Caretui 
observation of the patient is essential II superinlec lipn 
occurs during therapy, appropriate measures shnuld 
be taken ^ . . 

Positive direct Coombs tests have been reported 
during tteatment with the cephalosporin antibiotics In 
hematologic studies or in iranstusion cross-matching 
procedures when antiglobulin lests are perlormed on 
(he minor side or in Coombs teshng ol newborns 
whose mothers have received cephalosporin antibiolics 
belore parturition, it should be recogntted that a 
positive Coombs test may be due to the drug 

Ceclor should be administered with caution in the 
presence ol markedly impaired renal lunction Under 
such a condition, caretui clinical observahon and 
laboratory studies should be made because sate 
dosage may be lower than thai usually recommended 

As a result ot administration of Ceclor. a lalse- 
positive reaction for glucose in the urine may occur 
This has been observed with Benedict s and Feb ing s 
solutions and alsd with Clinitesr tablets but no with 
Tes-Tape- (Glucose Enzymatic Test Strip. UbK Liiiyl 
Usarje m Pregrancy— Although no teratogenic or 
anlifertility eltects were seen in reproduclion studies 
in mice and rats receiving up to 12 limes the 
maximum human dose or in ferrets given three times 
the maximum human dose, me satety ol this drug lor 
use in human pregnancy has not been established 
The benefits ol the drug in pregnant women should 
be weighed aoainsi a possible risk to the telus 

Usage m /n;ancy— Salely ol this product tor use m 
infants less than one month ol age has not been 
established 



Some ampicillin-reslstant strains of 
HgemoEhiius influenzae- a recognized 
complication of bacterial bronctiitis'-are 
sensitive to treatment wittn Ceclor; ^ 

In clinical trials, patients with bacterial bronchitis 
due to susceptible strains of StreQtococcus 
nneumoniae , H. influenzae. S, Qyogenp 
groupAbeta-hemolytic streptococci), or multiple 
organisms achieved a satisfactory clinical 
response with Ceclor/ 





fBfoclor 



I 



Adverse Reactions: Adverse eflecls considered related 
to cetaclor therapy are uncommon and are listed below: 

Gaslrmnleslinal symptoms occur in about 2 5 
percent of palients and include diarrhea (1 in 70) and 
nausea and vomiting (t in 90) 

Hvpersensilmly reactions have been reported n 
about 1 5 percent ot pahents and include morbilliform 
eruptiPhsll in 100) Pruritus, urticaria andpdSihve 
CoomOs tests each occur in less than 1 in 200 patients 

Cases pi serum-sickness-like reactions, including 
the above skin manilestations.feveT and 
arthralgia arthritis, have been reported Anaphylaxis 
has alsp been reported 

Olher elleds considered related to therapy included 
eosinophilia (1 in 50 palients) and genital prurdus or 
vaginitis Hess than 1 in 100 patientsi 

Causal Relalwnship Uncerlain— Transitory 
abnormalities in clinical laboratory test results have 
been reported Althpugh they were ol uncertain 
etiology, they are listed below to serve as alerting 
intormation lor the physician 

Hepa/ic— Slight elevations in SCOT SI3PT. ot 
alkaline phosphatase values (1 in 40) 

Hemalopoie/ic— Transient llucluations in leukocyte 
count, predominantly lymphocytosis occurring in 
intants and young children (1 in 40) 

Hena/— Slight elevations m BUN or serum 
creatinine (less than 1 in 500) or abnormal urinalysis 
(less than 1 in 200) l^"™" 



Pulvules- . 250 and 500 mg 



■ Many authorities attribute acute infectious 
exacerbation ol chronic bronchitis to eitherb 
pneumoniae or H intluemae ' 
A/ore Ceclor' (cetaclor) is contraindicated in patienVrl 
with known allergy 10 the cephalosporins and should 
be given cauliously lo penicillin-allergic patients 

Penicillin is the usual drug ol choice in me 1 ealme 
and prevention ol streptpcoccal infections, including 
the prophylaxis ol rheumatic lever See prescribing j 
intormation 
References 

1 Antimicrob Agents Chemother . 8 91. 1975 : 

2 Antimicrob Agents Chemother . I / 470.1977 

3 Antimicrob Agents Chemomer . 13584. 1978 

4 Amimicrob Agents Chemomet. 12 490. 1977 

5 Currem Chemotherapy (edited by )«Siegenthaler, 
andR Lulhyj.ll 880 Washington. D C Amcnc, 
Society for Microbiology. 1978 

6 Antimicrob Agents Chemother . I3;86f .1978 

7 Data on hie. Ell Lilly and Company 

8 Principles and Practice dllnleclipus Diseases 
(edited by GL Mandell.RG Douglas, Jr and J 
bennelt) p 487 New York John Wiley & Sons. lL 



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Prescribe new formula 

Quinamm' 

(quinine sulfate tablets) 



;h tablet contains quinine sulfate 260 mg 



\ 






^ 



/. 



/ 



Specific therapy for 
painful night leg cramps 

Merrell Dow 



Nocturnal recumbency leg muscle 
cramping is frequently an unwelcome 
bedfellow for many patients — especially 
those with arthritis, diabetes, or peripheral 
vascular disease . . . consider Quinamm . . . 
simple, convenient dosage — usually just 
one tablet at bedtime . . . can provide restful, 
welcome sleep without night leg cramps. 



■Trademark ot MERRELL-NATIONAL LABORATORIES Inc.. 
Cayey, Puerto Rico 00633 



luinamm' 



uinine sulfate tablets) 

.UTION Federal law prohibits dispensing without prescrrplion 

llEF SUMMARY 

DICATIONS AND USAGE 

the prevention and ttealment ol nocturnal recumbency leg muscle cramps. 
NTRAINDICATIONS 

inamm may cause letai fiarm when administered to a pregnant woman 
Ingenital malformations m the human have been reported with the use ol 
itiine. primarily wilh large doses |up lo 30 g ) for atlempled abortion In about 
I ol these reports ihe malformation was dealness related to audtlory nerve 
loplasia Among the other aCinormalilies reponeil were limb anomalies, vis- 
I' al deiecis, and visual changes in ammai tests, teratogenic effects were found 
.rabbils and guinea pigs and were absent m mice. rats. dogs, and monkeys 
(inamm is coniraindicated in women who are or may become pregnant II this 
ig is used during pregnancy, or if the patient becomes pregnant while taking 
^ drug, the palieni should be apprised ol the potential hazard lo the 'etus. 
:ause ol the qumme content, Oumamm is contraindicaled in patients wilh 
iwn quinine hypersensitivity and in palients with glucose-6-pho5phaIe dehy- 
genase (G-6-PD) dedciency 

ce ihrombocylopenic purpura may lollow the administration of qumme in 
hiy sensitive palients, a hisiory of this occurrence associated with previous 
-line mgeslion coniramdicaies iis further use Recovery usually occurs fol- 
ing withdrawal Of the meOicalion and appropriate therapy 
; drug should nol be used m patients with tmnilus or opiic neunlis or in 
lenis wilh a history of blackwaler lever 
UNINGS 

lealeO doses or overdosage ol qumme m some individuals may precipilale a 
jiler ol symptoms referred lo as cinchonism Such symptoms, m ihe mildest 
pi, include ringing in Ihe ears, headacfie, nausea, and slightly disturbed 
ren; fiowever. when medication is continued or after large smgte doses, 
Jiploms also involve the gastromieslmal tract, the nervous and cardiovascular 
■(ems. and the skin 

loiysis (with Ihe potential lor hemolytic anemia) has been associated with a 
■PD deficiency m palients taking gumine Quinamm should be slopped 
mediately if evidence of hemolysis appears. 

ympioms occur, drug should be discontinued and supportive measures 
'tuled In case of overdosage, see OVERDOSAGE section of prescribing 
rmation 
CAUTIONS 
?ral 

lamm should be discontinued if there is any evidence of hypersensitivity 
CONTRAINDICATIONS ) Cutaneous flushing, pruritus, skin rashes, fever 
nc distress, dyspnea, ringing in the ears, and visual impanmenl are Ihe 
II expressions of hypersensitivity, particularly il only small doses of quinine 



have been taken Extreme flushing ot ihe shin accompanied by intense, 
generalized prunlus is Ihe most common form Hemoglobinuria and aslhma 
from qumme ate rare types ol idiosyncrasy. 

In patients with atrial liOnllation. itte administration ol qumme requires ihe same 
precautions as Ihose lor qumidine (See Dru g Interactions ) 
Drug Interaciio ns 

Increased plasma levels ol digoKin and digiloxm have been demonstrated in 
individuals after concomitant qumidme administration Because ol possible simi- 
lar effects Irom use ol qumme it is recommended ihal plasma levels lor digoxm 
and digiloxm be determined lor those individuals taking these drugs and 
Oumamm concomitantly 

Concurrent use o( aluminum-containing antacids may delay or decrease absorp- 
tion of qumme 

Cinchona alkaloids, including qumme. have the potential to depress the hepatic 
enzyme system that synthesizes the vitamin K-dependenl factors The resulting 
hypoprolhrombmemic effect may enhance the action ol warfarin and other oral 
anticoagulants 

The eftecls ot neuromuscular blocking agents (particularly pancuronium suc- 
cmytcholine, and tubocuranne) may be poientialed with qumme and result m 
respiratorv ditficuiiies 

Urinary aikaiizers (such as acelazoiamide and sodium bicarbonate) may increase 
qumme blood levels wilh poteniial lor toxicity 
Drug Laborator y Interaciions 

(Jijinme may produce an eievaled value lor urmary l7-kelogenic steroids when 
the Zimmerman method rs used 
Carcinogenesis Muta g enesis im pairment ol Pertilil y 
A study ol qumme sullate administered m dnnking water (0 fo) to rats lor 
periods up to 20 months showed no evidence ol neoplastic changes 
Mutalion studies ol qumme (dihydrochiorrde) m male and female mice gave 
negative results by the micronucieus test Intraperitoneal injections (0 5 mM 
kg I were given twice. 24 hours apart. Direct Salmonella typnimunum tests 
were negative, when mammalian liver hemogenale was added positive results 
were (ound 

No information relating to the effect of qumme upon fertility m animal or m man 
has been lound 
Pregnancy 

Category X See CONTRAINDICATIONS. 
Nontetato o enic Effects 

Because quinine crosses the placenta in humans. Ihe potential lor (elal eflecis is 
present Stillbirths in mothers taking qumme have been reported in which no 
obvious cause lor the fetal deaths was shown Qumme m toxic amounis has been 
associated with abortion Whether Ihis action is always due to direct effect on the 
uterus IS questionable 
Nursin g Mothers 

Caution should be exercised when Oumamm is given to nursing women because 
qumme is excreted m breast milk (m small amounis) 



ADVERSE REACTIONS 

The loiiowing adverse reactions have been reported with Oumamm m therapeutic 
or excessive dosage (Individual or multiple symptoms may represent cin- 
chonism or hypersensitivity ) 

Hematologic acute hemolysis, thrombocytopenic purpura, agranulocytosis. 
hypoprothrombmemia 

CNS visual disturbances, including blurred vision with scoiomala photophobia, 
diplopia, diminished visual lieids and disturbed color vision, tinnitus dealness, 
and vertigo, headache, nausea, vomiting, lever, apprehension, restlessness 
confusion, and syncope 

Dermalologic allergic cutaneous rashes (urticarial the most liequeni lype of 
allergic reaction, papular, or scarlatinal) pruritus. Hushing ol Ihe skin, sweating. 
occasional edema of the face 
Respiratory asthmatic symptoms 
Cardiovascular angmal symptoms 

Gaslromlestinal nausea and vomiting (may be CNS-relaled), epigastric pam 
DRUG ABUSE AND DEPENDENCE 

Tolerance abuse or dependence with Oumamm has nol been reported 
OVERDOSAGE 

See prescribing mlormation lor a discussion on symptoms and treatment of 
overdose 

DOSAGE AND ADMINISTRATION 

1 tablet upon retiring It needed, 2 tablets may be laken nightly— l loiiowmg the 
evening meal and l upon retiring 

Afler several consecutive nights m which recumbency leg cramps do not occur 
Oumamm may be discontinued in order to determine whether continued therapy 
IS needed 

Pfoduc! Inlormation as ol October. 1980 

Licensor ol Merrell ' 

MERRELL-NATIONAL LABORATORIES Inc 
Cayey. Puerto Rico 00633 



Direct Medical inquiries lo 

Merrell 



MERRELL DOW PHARMACEUTICALS INC, 

Subsidiary of The Dow Chemical ComFiany 

Cincinnati, OH 4521 S. U.S. A 



Yd37ClMNQ-699 



Although weight loss achieved in a weight 
control program varies from patient to patient, 
this simulated sequence of a professional mode 
illustrates dramatically the benefits of a 
successful weight loss program. 




Cisagetting there. 



. .takes dietary restriction, regular exercise, 
behavior modification, and sometimes 
ihe addition of an effective anorectic. 

brescribe 

Ibnuate Dospan e 

idiethylpropion 
lydrochloride USP) 



'5 mg controlled-release tablets 



ie#1 prescribed anorectic 

.n effective short-term adjunct 
an indicated weight loss 
rogram 

^/erweight patients in certain diagnostic categories 
ten require strict obesity control. Diethylpropion 
'drochloride has been reported useful in obese 
itients with certain complications. While it isnotsu g- 
isted that Tenuate in any way reduces these com pli- 
itions in the oven/vei qht, it may have a useful place 
i a short-term ad j unct in a prescribed dietar y reqi- 
en. Tenuate should not be administered to patients 
th severe hypertension; see additional Precautions 
id Adverse Reactions on this page. 

I uncomplicated obesity 

ny patients, on the other hand, present vt/ith excess 
but no disease. While this condition is often termed 
icomplicated obesity, complications of both a social 
id a psychologic nature may be distressingly real for 
3 patients. In these cases, a short-term regimen of 
nuate can help reinforce your dietary counsel dur- 
I the important early weeks of an indicated weight 
;s program. 

linical effectiveness 

e anorectic effectiveness of diethylpropion hydro- 
• loride is well documented. No less than 1 8 separate 

nuble-blind, placebo-controlled studies attest to its 
efulness in daily practice.'' And the unique chemistry 
jTenuate provides "... anorectic potency with mini- 
fl al overt central nervous system or cardiovascular 
mulation." ^ Compared with the amphetamines, 
thylproplon has minimal potential for abuse. 



bnuate- it maizes sense. 
|nd it's responsible medicine. 

lerrell Dow 

llistered Trademarks of MERRELL-NATIONAL LABORATORIES Inc., 

I ey. Puerto Rico 00633 

i-rances: 1 Citations available on request from Merrell Dow Pharmaceuticals Inc. , Cincinnati. 

145215 2 Hoekenga M T etaj; A comprehensive review of diethylpropion hydroctiloride, 

Bntral Mechanisms of Anorectic Drugs. S Garattini and R Samanin. Ed . New York. 

mPress. 1978, pp. 391-404. 



Tenuate @ 

(diethylpropion hydrochloride USP) 

Tenuate Dospan @ 

(diethylpropion hydrochloride USP) 
controlled-release 

AVAILABLE ONLY ON PRESCRIPTION 

Brief Summary 

INDICATION: Tenuate and Tenuate Dospan are indicated in the management of exogenous obesity 
as a short-term adjuTict (a few weeks) in a regimen of weight reduction based on caloric restric- 
tion The limited usefulness of agents of this class should be measured against possible risk fac- 
tors inherent in their use such as those described below. 

CONTRAIND I CATIONS: Advanced arteriosclerosis, hyperthyroidism, known hypersensitivity, or 
idiosyncrasy to the sympathomimetic amines, glaucoma. Agitated states. Patients with a history 
of drug abuse During or withm 1 4 days following the administration of monoamine oxidase in- 
hibitors, (hypertensive crises may result). 

WARNINGS: If tolerance develops, the recommended dose should not be exceeded in an attempt 
to increase the effect; rather the drug should be discontinued, Tenuate may impair the ability of - 
the patient to engage in potentially hazardous activities such as operating machinery or driving a 
motor vehicle; the patient should therefore be cautioned accordingly. When central nervous sys- 
tem active agents are used, consideration must always be given to the possibility of adverse in- 
teractions with alcohol. Drug Dependence. Tenuate has some chemical and pharmacologic 
similarities to the amphetamines and other related stimulant drugs that have been extensively 
abused. There have been reports of subiects becoming psycfiologicaliy dependent on diethyl- 
propion. The possibility of abuse should be kept in mind when evaluating the desirability of in- 
cluding a drug as part of a weight reduction program. Abuse of amphetamines and related drugs 
may be associated with varying degrees of psychologic dependence and social dysfunction 
which, in the case of certain drugs, may be severe. There are reports of patients who have in- 
creased the dosage to many times that recommended Abrupt cessation following prolonged 
high dosage administration results in extreme fatigue and mental depression; changes are also 
noted on the sleep EEG. [Manifestations of chronic intoxication with anorectic drugs include se- 
vere dermatoses, marked insomnia, irritability, hyperactivity, and personalty changes. The most 
severe manifestation of chronic intoxications is psychosis, often clinically indistinguishable from 
schizophrenia. Use in Pregnancy Although ratan(] human reproductive studies have not indi- 
cated adverse effects, the use of Tenuate by women who are pregnant or may become pregnant 
requires that the potential benefits be weighed against the potential risks. Use in Children: 
Tenuate is not recommended for use in children under 12 years of age. 
PRECAUTIONS: Caution is to be exercised in prescribing Tenuate for patients with hypertension 
or with symptomatic cardiovascular disease, including arrhythmias. Tenuate should not be ad- 
ministered to patients with severe hypertension. Insulin requirements in diabetes mellitus may be 
altered in association with the use of Tenuate and the concomitant dietary regimen. Tenuate may 
decrease tfie hypotensive effect of guanethidme. The least amount feasible should be prescribed 
or dispensed at one time in order to minimize the possibility of overdosage. Reports suggest that 
Tenuate may increase convulsions in some epileptics. Therefore, epileptics receiving Tenuate 
should be carefully monitored . Titration of dose or discontinuance of Tenuate may be necessary. 
ADVERSE REACTIONS: Cardiovascular: Palpitation, tachycardia, elevation of blood pressure, 
precordial pain, arrhythmia. One published report described T-wave changes in the ECG of a 
healthy young male after ingestion of diethylpropion hydrochloride. Central Nervous System: 
Overstimulation, nervousness, restlessness, dizziness, jitteriness, insomnia, afixiety, euphoria, 
depression, dysphoria, tremor, dyskinesia, mydriasis, drowsiness, malaise, headache; rarely 
psychotic episodes at recommended doses In a few epileptics an increase in convulsive epi- 
sodes has been reported . Gastrointestinal ■ Dryness of the mouth, unpleasant taste, nausea, 
vomiting, abdominal discomfort, diarrhea, constipation, other gastrointestinal disturbances. 
Allergic: Urticaria, rash, ecchymosis, erythema. fnc/ocA/ne.' Impotence, changes in libido, 
gynecomastia, menstrual upset. Hemaropo/ef/cSys/em. Bone marrow depression, agranulo- 
cytosis, leukopenia. Miscellaneous A variety of miscellaneous adverse reactions has been 
reported by physicians These include complaints such as dyspnea, hair toss, muscle pain, 
dysuna, increased sweating, and polyuria 

DOSAGE AND ADMINISTRATION: Tenuate (diethylpropion hydrochloride): One 25 mg. tablet 
three times daily, one hour before meals, and in midevening if desired to overcome night hunger. 
Tenuate Dospan (diethylpropion hydrochloride) controlled-release: One 75 mg . tablet daily, swal- 
lowed whole, in midmorning Tenuate is not recommended for use in children under 12 years 
of age. 

OVERDOSAGE: Manifestations of acute overdosage include restlessness, tremor, hyperreflexia, 
rapid respiration, confusion, assaultiveness, hallucinations, panic states. Fatigue and depression 
usually follow the central stimulation. Cardiovascular effects include arrhythmias, hypertension 
or hypotension and circulatory collapse Gastrointestinal symptoms include nausea, vomiting, 
diarrhea, and abdominal cramps. Overdose of pharmacologically similar compounds has re- 
sulted in fatal poisoning, usually terminating in convulsions and coma, f^anagement of acute 
Tenuate intoxication is largely symptomatic and includes lavage and sedation with a barbiturate. 
Experience with hemodialysis or peritoneal dialysis is inadequate to permit recommendation in 
this regard. Intravenous phentolamme (Regitine") has been suggested on pharmacologic 
grounds for possible acute, severe hypertension. ifthiscomplicatesTenuateoverdosage- 

Product Information as of June. 1980 
Licensee of fi^errell- 

IVIERRELL-NATIONAL LABORATORIES Inc. 
Cayey, Puerto Rico 00633 

Direct Medical Inquines to: 



Merrell 



-^^jj^ 



lUIERRELL DOW PHARMACEUTICALS INC. 

Subsidiary of Ttie Dow Chemical Company 

Cincinnati. OH 4521 5. U.S.A. 



m 



m % 



GIARDIASIS. 

NOW THERE 

IS A BEHER METHOD 

o OF DIAGNOSIS 

WHEN STOOL EXAMS ARE 

NEGAriYE. 



I 



* 



• 




ENTERO-TEST* A 140cm nylon line 
coiled inside of a gelarin capsule 
designed to retrie\e duodenal 
contents without intubation. EasiU- 
administered and tolerated. 
ENTERO-TEST' has the following 
ad\antages: 

• A \-iable alternati\e to intubation 

• Well tolerated by all age groups 

• Pediatric sizes available 

• Useful in the diagnosis of bleeding 
and a variety- of intestinal parasites 

Rosenthal and Leibman studied 23 
pediatric patients udth diarrhea. All 
had one or more negative stools. Of 
these, 5 patients had Giardia lamblia 



which was diagnosed b\- the simple 
ENTERO-TEST* procedure. Lopez 
and co-workers diagnosed 
C;iardiasis in 22 patients 
with the EXTERO-TEST® 
compared to 4 patients by 
stool exams. ENTERO- 
TEST* has pro\-ed to be a 
useful and eftecri\'e method 
for the localization of upper 
GI bleeding, and the diag- 
nosis of Ts-phoid carriers, 
strongv'loidiasis and other 
parasitic diseases. 



References: 

Rosenthal, P.. and Liebman,\\'.M: Comparati\e 

stuci\- of stool examinations, duodenal aspiration, 

and pediatric Entero-Test for giardiasis in 

children.,/. I'EDIAT. 96: 278 (Feb.) 1980. 

Thomas. (;. E.. et al: I'se of the Entero-Test 

duodenal capsule in the diagnosis of giardiasis. 

South Afr. Med I 4S: 2219. 1974. 

Lopez. M. E., et al: Infeccion duodeno-ye\-unal en 

el nino con desnutrician energetico-protcinica. 

Rev. Med. Hasp. Xat. \'inos 13: n.i. 1978. 

(iilman. R. H: Identification of gall 
lA-phoid carriers b\' a string 
bladder device. The Lancet: 
\pril 14. p. 795. 1979. 



HEDECa 




ENTERO-TEST,® The Solution. Simple And Convenient. 



(800) 227-8162 

2551 Casty Avt". 
Mountain View 
California 94043 



PRESIDENT'S ACCEPTANCE SPEECH 



JOSEPHINE E. 
Josephine E. Newell, M.D., F.A.A.F.P. Born May 
21, 1925. Educated Dreher High School, Columbia, 
S.C., University of South Carolina, University of 
Maryland School of Medicine. Internships, Women's 
Hospital, Baltimore, Md., and Rex Hospital, Raleigh. 
Residency, Rex Hospital. General Practice, Bailey, 
N.C., 1951-1975. Present position, medical director. 
Electronic Data Systems Federal Corp., Raleigh. Pro- 
fessional affiliations: President, vice president, 
secretary-treasurer and board of censors, Wilson 
County Medical Society; convention and education 
commission chairman, scientific exhibits chairman, 
auxiliary advisory chairman, finance consultant, 
cancer consultant, first vice president, president elect 
and president, N.C. Medical Society; chairman of an- 
nual session, N.C. Academy of Family Practice; chair- 
man, Wilson Memorial Hospital Symposium; fellow, 
American Academy of Family Practice; American 
Medical Association. Founder and president. Country 
Doctor Museum. Coordinator, Breast Cancer Detection 
Demonstration Project, Durham (1975-79), associate. 
Department of Radiology, Duke University Medical 
Center (1976-79), associate, Department of Community 
and Family Medicine, Duke University Medical Center 
(1975-79); adjunct assistant professor of community 
and family medicine, Duke University Medical Center, 
1979-continuing. 



Good evening. As usual, I'm flattered to be seated 
up here with all these distinguished ladies and gentle- 
men — presidents and past-presidents of both the 
North Carolina Medical Society and its auxiliary. One 
would think that I would be familiar with this place. 
For years and years. I have sat on one side or the other 
of these two tables. Once or twice I've mastered the 
ceremony — I may have just invented that phrase, but 
you know that a "career old maid" would never admit 
to "mistressing" anything. Then. I've been a vice- 
president, president-elect and one thing or another. 
Matter-of-fact, I think my name is painted on the 
bottom of one of these chairs — probably, so I can 
claim my own chewing gum — well, I didn't think that 
I was one bit nervous — until — Past-president 
George Gilbert pointed out that, tonight, I'm sitting in 
the "fingered" chair! "Miss Manners" would never 
believe or smile on the unspeakable gesture which 
accompanied that remark! 

For a while there, I thought I had been moved up on 

the program. 01" Ben Warren leaned over and said, 

"Jo, should we let 'em enjoy their dessert and coffee 

— or do you want to go ahead with your speech?!" 

I truly am serious about my message to you tonight. 

Finally, my opportunity has come to publicly express 

the depth of my gratitude for the tremendous honor 

which you have bestowed upon me, by electing me 

president of the North Carolina Medical Society. In 

I truth, there is no appropriate language which can 

' properly express either my deep appreciation or the 

■ profound sense of humility which I feel, this very 



NEWELL, M.D. 

instant, and which has been my constant companion 
for the 12 months in which I have known that, tonight, 
I would assume an awesome responsibility — presi- 
dent of the North Carolina Medical Society. 

It's the custom to introduce one's family before 
making this acceptance speech to the society. Since 
my few blood relatives live far away from Pinehurst, I 
have always considered the members of this society to 
be my real family. So, while it would not do for me to 
introduce you to each other, you have, in a very real 
sense, been my family; and the welfare and future of 
this society have been my avocation for the last 30 
years. 

I have been reminded that I am the society's first 
"lady" president. I never really thought myself un- 
usual because I am a woman and practiced medicine. 
The state of one's sex (if you will pardon the expres- 
sion) is neither a hindrance nor a help. I like to feel that 
I have paid my dues and made my contribution — 
whatever it might be — as has each of you. I am 
honored that you have elected me your president. 

The North Carolina Medical Society does have 
problems. There are some old ones left over from 
earlier times, some new ones that have appeared this 
last year, and, I am certain, there will be even more 
problems to go with these confused and changing 
times. 

We have just finished a management survey of the 
needs and the capabilities of our headquarters staff. 
The first information our survey team asked was: 
"What purpose does the medical society serve?" 
Why do members join our ranks? What services do we 
offer them? In other words, what do physicians expect 
when they pay their dues, and- — most important of all 
— what do we supply them? It may appear to be a 
foolish question, but Peter Drucker. the father of 
modem day management science, once noted: "The 
most important question any organization has to an- 
swer is 'what do we really do here?' 

When beset on every side by yet another threat 
which endangers the very foundation of our basic 
beliefs and our concept of the ethical practice of medi- 
cine, some of our members have entertained different 
philosophies. Certainly, this is not unexpected in an 
organization of educated people who are highly 
trained to think, reason and "make judgments" every 
hour of the day. I am grateful that our society provides 
a democratic forum where we may come together and 
reason with each other concerning these philosophical 
differences. I believe that we share an invincible 
common goal — the best possible medical care for 
every person whom we encounter. 

Unlike Hippocrates, we can no longer confine our- 
selves to the pure practice of medicine. We have been 
forced into a world of politics, with which we are 
unfamiliar. When America was first settled, physi- 
cians accepted roles as politicians, statesmen, sol- 
diers, teachers and even ministers. They comprised a 
great number of the "Founding Fathers." Perhaps the 
time has come when physicians must again take up 



August 1981. NCMJ 



541 



such a mantle. For the past two decades, we have been 
so engrossed in technological advancement and rapid 
changes in medical care that we have been content to 
allow others, who were willing, to manage civic affairs 
which are vital to every citizen of this great nation. We 
must maintain the search for truth in our world. We 
must, again, assume leadership roles in our commu- 
nity. Rousseau said: "As soon as public service 
ceases to be the chief business of the citizens, and they 
would rather serve with their money than their per- 
sons, then the state is not far from its fall." 

We must hold fast to the fellowship that physicians 
have known since the beginning of time. There must 
be no dissension among us. We must be united in our 
compelling drive to retain for our patients the best 
health care ever known to any civilization. 

Now, friends — I want to assure you that I am going 
to honor all of the promises I make tonight. However, 
I would appreciate it if Gloria Graham, Sarah Morrow 
and Marshall Redding would stop taking notes. 

We must address the subject oi membership. When 
the census was taken last year, I filled my form out in 
Raleigh. I understood the directions to say "Where 
are you sleeping tonight?" A leading question — and 
I'm sorry to say that my answer could in no way be 
provocative — more's the pity. Of course, two or 
three of those forms were left at my house in Bailey — 
and at the Museum. I went to the mayor to return all 
the extras and he told me that the population count had 
remained the same in Bailey, as with the last census. I 
just couldn't understand how that could happen with 
all those babies being born. (Bailey has been known as 
a sexy place, to those who don't know any better.) 
Well, the mayor explained, "Every time a new baby is 
born, some fellow has to leave town!" Well, so it must 
be with our medical society. In the past several years, 
growth of our membership has not kept pace with the 
great influx of physicians entering practice in North 
Carolina. I intend to appoint an ad hoc committee to 
address this problem and, tonight, I challenge the 
incoming officers of this society, the Executive Coun- 
cil, the House of Delegates and every member of the 
North Carolina Medical Society to join me in an effort 
to personally contact every new physician in every 
community in North Carolina with a warm, sincere 
invitation to join our fellowship. While we, as indi- 
viduals, may disagree with some of the positions taken 
by our county, state and national medical organiza- 
tions, we must never forget that our House of Dele- 
gates is the deliberative body which formulates the 
policies governing the practice of medicine in North 
Carolina. One must be a member of any organization 
in order to participate in its deliberations. 

Tom Paine admonished us: "Those who expect to 
reap the benefits of freedom must, like men and 
women, undergo the fatigue of supporting it." 

I would urge you to reinstitute district meetings for 
the purpose of nominating your councilors when ap- 
propriate, and just as important, to consider the 
socio-economic problems which impact the practice 
of medicine. Unity is influence. I believe that it is our 



duty to influence, through education, our political 
leaders, in the best interest of health care of Ameri- 
cans. 

I have met with the president-elect and vice presi- 
dents of our society. We share the belief that the 
membership is the North Carolina Medical Society. 
We are united in our determination to increase mem- 
bership in order that our society will continue, not 
only as the recognized voice of practicing physicians 
in North Carolina, but also as an outspoken power for 
the best interests of all North Carolinians. 

The president-elect, vice presidents and I stand 
ready to visit with county societies and district 
societies to bring the message of this administration to 
the membership. The message is unity. Unity through 
fellowship and open discussion of our mutual prob- 
lems and our mutual ambitions. 

Now, there may be as many opinions as to the 
purpose this society serves — or should serve — as 
there are people in this room. To me, the North Caro- 
lina Medical Society has represented fellowship, an 
opportunity to gather with colleagues and discuss 
those problems which face us all, and even an oppor- 
tunity to disagree and argue about how we can best 
face those problems and solve them. To do that effec- 
tively, 1 am convinced we must listen carefully to all 
our members, and once we have a consensus, we must 
move together. We are too few in number to be effec- 
tive as individuals. We must give to our members 
some dim perception that — while we are not slaying 
many dragons — we are surely wearing their armor, 
carrying their sword, and trying to carry out their 
wishes. Our failure to enlist a proportionate number of 
new doctors into our ranks persuades me that we have 
not managed to get that message across very well. 

I like the story about the Jewish sergeant during the 
first Israeli-Arab war who was stopped by an officer as 
he ran — alone — toward the battlefield. Asked where 
he was going he replied, "My men wanted to attack, 
but I felt we should wait another few minutes. Now 
they have gone ahead without me and I must catch up 
- — because my place is at the head of the column." I 
intend to find out where the members of this society 
wish us to go. 1 want to find out what priorities you 
have. Then we must sit down and hammer out any 
differences that exist, and we will try to move out 
together. If my personal feelings are at odds with the 
final decision, like the sergeant in the story, I intend to 
run, as fast as I can, because I feel my position — like 
his — is at the head of the column. 

You do me great honor by entrusting this society to 
my leadership for the coming year. I will need your 
help, your good will, and your affection. In return I 
shall give you my very best effort. 

St. Paul advised the Thessalonians: "Hold fast to 
that which is good." We shall hold fast to the North 
Carolina Medical Society because it is good. 

Thank you for the honor and the privilege to serve 
as president of the nicest people I know — the mem- 
bership of the North Carolina Medical Society. 



Acceptance remarks, Pinehurst, N.C., May 9, 1981. 



542 



Vol. 42, No. 8 




Josephine E. Newell, M.D. 
President, North Carolina Medical Society 



J 



Prescription Medication in the Workplace 

Occupational Absenteeism, Accidents, and Performance 
When Using Non-Psychoactive and Psychoactive Medication 

Richard C. Proctor, M.D. 



ABSTRACT A survey of 2,200 em- 
ployees of three manufacturing firms 
investigated the effect of prescription 
medication (particularly psycho- 
actives) on occupational safety, ab- 
senteeism and job performance. 
Questionnaires completed by 762 
employees showed no statistically 
significant difference in perfor- 
mance, accidents or days out re- 
gardless of the type of prescription 
product used. Furthermore, psycho- 
active medications did not appear to 
introduce a significantly greater oc- 
cupational liability than any other 
group of prescription products. 

OVER the past several years, 
numerous articles have ap- 
peared in every form of lay media on 
stress and anxiety in the workplace. 
The final toll of severe stress of this 
type is often enormous both eco- 
nomically in terms of absenteeism, 
accidents and poor performance, 
and physically in the development 
of organic and emotional illness and 
alcoholism. Psychoactive medica- 
tions, mainly of the minor tran- 
quilizer class and most often in the 
form of diazepam, have generally 
been the treatment of choice for this 
emotional distress. Now this ther- 



Professor and Chairman of the Department of Psychiatry 
and Behavioral Medicine. Bowman Gray School of Medi- 
cine of Wake Forest University. 300 South Hawthorne 
Road. Winston-Salem. N.C. 27103 



apy is also coming under criticism in 
the same lay media. '"' Articles 
containing charges of tranquilizer 
overuse and misuse may also pre- 
sent anecdotal case histories in 
which use of this type of medication 
resulted in a reduction of mental 
acuity and performance. However, 
a review of the scientific literature 
turns up few studies which have 
actually evaluated the effects of 
psychotherapeutic agents on skilled 
performance in the workplace. Pre- 
vious research with chlordiaze- 
poxide on patients in an industrial 
setting found no detriment to per- 
formance, but rather increased pro- 
duction correlated with the symp- 
tomatic improvement of anxiety. ^'^ 
As a result of this research, an ex- 
ploratory investigation of the ef- 
fects of a wide range of commonly 
prescribed psychoactive and non- 
psychoactive drugs was under- 
taken, with special interest in the 
effects of diazepam. In addition to 
worker performance, absenteeism 
and accident rates were also re- 
corded. 

METHOD 
Sample and Survey Instrument 

Our survey covered 2,200 em- 
ployees of three large manufactur- 
ing firms engaged in the production 
of fine wood furniture. A simple 
three-page questionnaire (Table I) 



August 1981. NCMJ 



was developed, listing the 25 most 
commonly prescribed prescription 
medications including diuretics, 
antibacterials, sedatives, antihis- 
tamines, analgesics, antispasmod- 
ics, anti-inflammatory agents, es- 
trogens, antidepressants, and minor 
tranquilizers (benzodiazepines)." 
The most familiar product name 
was provided — whether brand or 
generic — to facilitate patient iden- 
tification. Respondents were asked 
to check those medications "you 
are taking now or have taken in the 
past six months." It was suggested 
that the name of the medication be 
confirmed with the pharmacists' la- 
bels appearing on the containers. 
An additional space was provided 
for indicating if no medication had 
been taken over the past six months. 
If respondents indicated medica- 
tion had been utilized, they were 
instructed to "choose the two 
medications used most recently" 
and answer the six questions on the 
next two pages of the questionnaire 
— one page for each medication 
taken. The six questions included 
name of medication, why it was pre- 
scribed, date of starting medication, 
last time taken, dosage strength and 
dosage schedule (from label). 

Procedure 

Distribution of the questionnaire 
was preceded by a letter to all em- 

545 






ployees from management explain- 
ing the company's participation in a 
health survey being conducted by 
Bowman Gray School of Medicine 
and soliciting cooperation. Ques- 



tionnaires plus a cover letter were 
distributed shortly thereafter and 
response was requested within 48 
hours. Questionnaires carried iden- 
tification numbers which permitted 



TABLE I 

THIS QUESTIONNAIRE IS CONCERNED WITH THE USE OF A NUMBER OF DIFFERENT MEDICATIONS' 
Before you begin answering questions about medications, please identify your sex by cfiecking the appropriate box. 

D 1. Male n 2- Feinale 

Listed below are several prescription medications commonly recommended by doctors. Each medication has a small 
box in front of it. Please CHECK THE BOX OF ANY MEDICATIONS YOU ARE TAKING NOW OR HAVE TAKEN IN THE PAST 
SIX MONTHS. You may want to look at the druggist's label on the container of the medication to make sure of some 
names. 



not. None of the Following 

D02. Actifed»t 

D 03. Ampicillin 

D 04. Benadril* (diphenhydramine)* 

DOS. Dalmane" (flurazepam)' 

D06 Darvocet-N't 

D07. Donnatal«t 

a 08. Dyazide»t 

D09. Elavil' (amitriptyline)* 

D 10. Fiorinal't 

Dll. HydroDIURIL» (hydrochlorothiazide)* 

D 12. Ilosone' (erythromycin estolate)* 

n 13. Inderal'^ (propranolol)* 



D 14. Indocin* (indomethacin)* 

D 15. Keflext (cephalexin)* 

D 16. Lanoxin'' (digoxin)* 

D 17. Lasix Oral^ (furosemide)* 

D 18. Librium^ (chlordiazepoxide)* 

D 19. Lomotil't 

D 20. Motrin^ (ibuprofen)* 

n21. Percodan^t 

D 22. Phenobarbital 

D 23. Premarin Oral' (conjugated estrogen)* 

D 24. Sumycin'' (tetracycline)* 

n 25. Valium^ (diazepam)* 

26. V-Cillin-K» (penicillin V)* 



IF YOU CHECKED NONE, please RETURN THIS FORM in envelope provided. 

IF YOU CHECKED ONE OR MORE BOXES, please read the following instructions and complete the following pages. 

INSTRUCTIONS: The next two pages are divided into two sections At the top of each section is a blank line labeled 

NAME OF MEDICATION ■ From the list of medications you checked. CHOOSE THE TWO MEDICATIONS YOU HAVE 

USED MOST RECENTLY AND WRITE THEIR IDENTIFYING NAMES FROM THE LIST ABOVE ON THESE LINES (one 

medication for each line). If you only checked two boxes, use those two names If you only checked one box, leave the 

second section blank. 

After you have written the number of the medications on the lines, answer the questions in each section by checking 
the appropriate boxes FOR EACH SECTION, PLEASE ANSWER THE QUESTIONS ABOUT THE MEDICATION NAME 
YOU WROTE ON THE LINE 

*Generic names are given in parentheses but were not indicated in the standard questionnaire. 
fConsfituents of compounds are given below but were not indicated in the standard questionnaire. 
Actifed* — triprolidine hydrochloride 2 5 mg and pseudoephedrine hydrochloride 60 mg per tablet 
Darvocet-N^ 50-propoxyphene napsylateSO mg and acetaminophen 325 mg; Darvocet-N^IOO-propoxyphene napsylate 

100 mg and acetaminophen 650 mg per tablet 
Donnatal'' — phenobarbital 16.2 mg, hyoscyamine 0.1037 mg, atropine sulfate 0.0194 mg, hyoscine hydrobromide 

0.0065 mg per tablet, capsule or teaspoonful 
Dyazide* — triamterene 50 mg and hydrochlorothiazide 25 mg per tablet 
Fiorinal'* — butalbital 50 mg, aspirin 200 mg, phenacetin 130 mg, caffeine 40 mg 

Lomotil^ — diphenoxylate hydrochloride 2.5 mg and atropine sulfate 0,025 mg per tablet or teaspoonful 
Percodan* — oxycodone hydrochloride 4.50 mg, oxycodone terephthalateO.38 mg, aspirin 224 mg, phenacetin 160 mg, 

caffeine 32 mg per tablet 

SECTION I 

Name of Medication 

1. For what reason(s) did your doctor prescribe this medication? 

2. When did you first start taking this medication? ■." 
D 1. More than one year ago 

D 2. More than six months, but less than one year ago 
D 3, Within the past six months 

3. When was the last time you took this medication? 
D 1 . More than one year ago 

D 2. Within the past month 

a 3. Within the past six months 

4. How often during the past six months did you take this medication every day? 
D 1. Less than one month C 3. Two to five months 

D 2. About a month D 4. All six months 

5. What size are the pills? (You will find this information on the druggist's label) 
D01. 1 - 4 mg. DOB. 60-99 mg 



D 02. 5 - 9 mg 

n03. 10-14 mg 

D 04. 15-19 mg 

O 05. 20-29 mg 

D 06. 30-39 mg. 

D 07. 40-59 mg 

What dose is wri 

D 1. One or two a day 

D 2. Three or four a day 



n09. 100-149 mg. 
D 10. 150-249 mg 
D 11. 250 + mg. 
D 12. Other 
D 13. Don't Know 

tten on the druggist's label? (If no dose is written, how many pills did the doctor tell you to take?) 
G 3. Five or more a day 
D 4. Don't know 



cross tabulation with employee rec- 
ords regarding health-related ab- 
senteeism, on-the-job accidents and 
supervisor's past rating of work 
performance. The latter ratings 
were measured on a numerical scale 
from 1 to 5 with the higher number 
indicating superior performance. 

RESULTS 

Seven hundred and sixty-two 
questionnaires were completed and 
returned, representing an antici- 
pated response of about one-third 
(34.6%) of the subject population. 

Performance for the subjects in 
this investigation had been mea- 
sured by their immediate foremen 
and supervisors and had been re- 
corded in personnel department re- 
ports. Absenteeism and accidents 
were also available through the per- 
sonnel department. 

To facilitate comparison, respon- 
dents were divided into several 
groups based on type of medication 
being taken, i.e., any, none, non- 
psychoactive, psychoactive and/or 
diazepam (Table II). Data for days 
absent, number of reported acci- 
dents and supervisor's rating of 
performance were tabulated and the 
means determined for each group 
(Table III). As would be expected, 
respondents taking no medication 
and, therefore, presumably well 
(N-581) scored better in all areas 
than those who had received some 
type of prescription medication 
within the past six-month period 
(N-lSl). The difference was most 
evident in absenteeism with the 
medicated group averaging three 
more days lost from the job. 

Those taking medicine were then 
categorized according to the effects 
of psychoactive or non-psychoac- 
tive medication on occupational in- 
dices. Subjects receiving common 
non-psychoactive medicines (N-1 14) 
lost less time from work (approxi- 
mately two days), had fewer acci- 
dents and had slightly better per- 
formance ratings than patients on 
any type of psychoactive drug 
(N-67). These 67 patients were then 
divided into two additional groups, 
those receiving psychoactive medi- 
cation such as amitriptyline, pro- 
poxyphene and phenobarbital 
(N-28), and those taking diazepam 



546 



Vol. 42. No. 8 



i 



(N-39). Although differences in time 
out from work were minimal, a dif- 
ference in accident rate and perfor- 
mance was noted between the two 
i groups. Since the number of sub- 
jects taking psychoactive drugs was 
quite small and the standard devia- 
tions very large, statistically signifi- 
cant differences were not to be ex- 
pected. 

DISCUSSION 

Although the limitations of these 
preliminary data are recognized, 
the available figures clearly suggest 
that (1) taking any medication is as- 
sociated with greater absenteeism 
which would be expected since the 
sick are more likely to receive 
medication as well as to be absent 
from work, and, (2) use of diazepam 
is not associated with any major 
difference in performance or in ac- 
cident or absentee rate above that 
observed in patients taking any 
other type of medication. There- 
fore, results from this survey show 
no increased negative effects in the 
workplace associated with diaze- 
pam use. These results should be 
;viewed, however, as only prelimi- 
nary. Additional studies involving 
larger groups of subjects working in 
other industries and in other geo- 
graphic regions are needed before 
making a blanket statement as to 
the effect of these drugs on worker 
performance, absenteeism and ac- 
cident rates. 

RefereDces 

1. Perry HJ. Baiter MB, et al: National patterns of 
psychotherapeutic drug usage. Arch Gen Psychiatry 
28:769-783. 1973. 

2. Lennard HL. Epstein LJ. Bernstein A. Ransom DC; 
Hazards implicit in prescribing psychoactive drugs. 
Science 169:438-441, 1970. 

3. Muller C: The overmedicated society: forces in the 
marketplace for medical care. Science 176:488-492, 
1972. 

4. Proctor RC: Psychiatry in an industnal setting. Arch 
Environ Health 3:63-68, 1%1. 

5. Proctor RC: Industrial psychiatry; An evaluation of 
chlordiazepoxide in patients in an industrial setting. 
Med. Times 89:1153-1158, 1%1. 

6. New Prescription Audit. IMS Amer. Ltd., 1978. 



TABLE I 

SECTION II 



August 1981. NCMJ 



Name of Medication 

1. For what reason(s) did your doctor prescribe this medication? 

2. When did you ttrst start taking this medication? 
n 1. More than one year ago 

D 2. More than six months, but less than one year ago 
D 3. Within the past six months 

3. When was the last time you took this medication? 
D 1 . More than one year ago 

D 2- Within the past month 

D 3. Within the past six months 

4. How long during the past six months did you take this medication every day? 
D 1. Less than one month :^ 3. Two to five months 

n 2. About a month c 4. All six months 

5. What size are the pills? (You will find this information on the druggist's label) 
O OL 1 - 4 mg. O 08. 60-99 mg 

DOS. 100-149 mg. 
D 10. 150-249 mg. 
nil. 250 * mg. 
D12, Other 
D 13. Don't Know 



D 02. 5 - 9 mg 

n03. 10-14 mg. 

D 04. 15-19 mg. 

D 05. 20-29 mg. 

n 06. 30-30 mg 

D 07, 40-59 mg 

What dose is written on the druggist's label? (If no dose is written, how many pills did the doctor tell you to take^ 
□ 1. One or two a day U 3. Five or more a day 

D 2. Three or four a day D 4. Don't know 



TABLE II— CATEGORIZATION OF RESPONDENTS 



No Medication 
581 




Non- psychoactive 
114 



TABLE III 
Comparison of Workplace Incidents by Type of Medication for Six Months 



N=762 









Days 


Absent 


Accidents 


Performance 


Rating 


Respondent 
Group 




















N 


Mean 


SD 


Mean 


SD 


Mean' 


SD 


No Medication 




581 


5,60 


6.09 


0,11 


.34 


3-45 


83 


Any Medication 




181 


896 


9.99 


0.12 


35 


3.36 


.76 


Non-Psychoactive 




114 


8.24 


8,53 


0.10 


.30 


3.36 


.74 


Medication 


















Psychoactive Medicat 


on 


67 


10.17 


12 06 


0.16 


41 


3.35 


.81 


Diazepam 




39 


9.87 


12.97 


0.12 


.40 


3.51 


,79 


All Other 


















Psychoactives 




28 


10.60 


10,89 


0.21 


.41 


3.14 


,80 


•Higher score indicates 


superior performance 













547 



J 



Illness Onset and Levels of Health Care Provided: 

AStudy of 213 Families 



Robert B. Taylor, M.D., Robert L. Michielutte, Ph.D. 
Anne Herndon, Ph.D. 



and 



ABSTRACT The occurrence of 
new illness in families and the levels 
of health care provided, as reported 
by family members at the Bowman 
Gray School of Medicine Family 
Practice Center, has been deter- 
mined. In a survey of 738 persons in 
213 families, 580 illnesses were re- 
ported during a six-month period; 
434 persons (59%) contacted a physi- 
cian. A physician other than the pri- 
mary physician was contacted 152 
times (21%) and 55 hospitalizations 
were reported. Comparfson of data 
with earlier studies revealed that our 
sample population had a relatively 
high rate of consultative/referral 
care and hospitalization. 

THIS paper describes a study of 
new illness occurring in family 
members and the levels of health 
care provided to these individuals in 
a family practice center located in a 
tertiary care facility. White et al' 
have pointed out that in the study of 
illness behavior the patient may be a 
more relevant unit of observation 
than the disease, the visit, or the 
hospital admission. Efforts to con- 
struct a model classification of rea- 
sons for contact with primary health 
care services have prompted re- 
newed interest in the ecology of 



From the Department of Family and Community Medicine 
Bowman Gray School of Medicine 

of Wake Forest University 
300 S. Hawthorne Road 
Winston-Salem. N.C. 27103 
Reprint requests to Dr. Taylor 



548 



health care. A 1979 preliminary re- 
port cites the "acute need to define 
better the complicated relationship 
between health care needs and de- 
mands."'- The levels at which health 
care is provided for illness become 
important in cost containment and it 
is generally agreed that increased 
availability and utilization of pri- 
mary health care services reduce 
the need for and use of more ex- 
pensive and specialized and. often, 
hospital-based health care.- 

Primary care has been defined as 
that furnished by "a physician of 
first contact, who provides con- 
tinuing comprehensive care, em- 
ploying referrals to other physicians 
when appropriate, and who or- 
chestrates the health care team and 
often acts as the patient's personal 
advisor."-' Secondary and tertiary 
care are less well defined. It has 
been stated that secondary care is 
that offered by consultants in or out 
of a hospital and that tertiary care is 
usually provided by the major 
teaching medical centers.^ How- 
ever, distinctions between these 
three levels of health care become 
clouded in many areas, notably so in 
the outpatient areas of teaching 
hospitals where Fletcher et al'' have 
suggested that secondary rather 
than primary care is most often ren- 
dered. Thus, the patient treated in a 
family practice center located in a 
tertiary care facility may encounter 
a pattern of care that differs from 
that in the community at large. 



Our study addressed the follow- 
ing questions: In the sample popu- 
lation of persons receiving primary 
care at a teaching hospital, how 
many new illnesses occurred and 
how often was the primary care 
physician consulted? How often 
was secondary or tertiary care re- 
quired and how often was hospitali- 
zation necessary? How do the an- 
swers to these questions compare to 
data regarding health care outside 
the teaching hospital? What are the 
reasons for any differences? 

METHOD 

The population consisted of fam- 
ilies registered at the Family Prac- 
tice Center of the Bowman Gray 
School of Medicine, Winston- 
Salem, North Carolina, which 
serves 4,500 pre-registered families 
who are representative of the com- 
munity. The Family Center is at- 
tached to the teaching hospital and 
medical school. 

A representative sample of 241 
persons was asked to complete a 
questionnaire that elicited the fol- 
lowing data: 

1 . Number of family members 

2. Number of new illnesses (the 
beginning of any sickness, in- 
jury or disability in the family 
members during the previous 
six months)" 

3. Number of times the family 
physician was consulted 

4. Number of times a physician 



Vol. 42, No. 8 



A 



otherthan the family physician 
was consulted 
5. Number of times hospitaliza- 
tion was required 

A research assistant presented 
the questionnaire to consecutive 
patients at one of three modules in 
the Family Practice Center, with 
patients in all three modules sur- 
veyed in rotation. Following brief 
examination of the questionnaire, 
20 patients declined to participate. 

Completed forms were obtained 
from 221 respondents, either a pa- 
tient or a family member accom- 
panying the patient: eight were in- 
validated as unusable. Some sample 
bias was introduced by the ten- 
dency of non-respondents and re- 
spondents returning unusable ques- 
tionnaires to be black or less well 
educated. However, since the over- 
all response rate was 88.4%, the loss 
of these individuals from the sample 
should have little effect on the re- 
sults. 

RESULTS 

The 213 respondents ranged in 
age from 18 to 83 (mean 38) years. 
Questionnaires received from these 
individuals reported illness onset 
and health care levels provided for 
738 family members. The respon- 
dents were 92% white/Caucasian, 
7% black/ Afro-American and 0.5% 
other races. Their education ranged 
from fewer than nine years of school 
(5.6%) to professional degree 
(9.4%). 

Figure 1 presents the number and 
percentages of new illnesses, con- 
sultations with a family physician, 
consultations with another physi- 
cian, and hospitalizations during the 
six-month period. Table I compares 
these data with the National Health 
Survey data obtained from supple- 
mental forms on acute conditions 
added to the Health Interview Sur- 
vey conducted by the U.S. Depart- 
ment of Health, Education and 
Welfare during calendar years 1973 
and 1974. Overthis two-year period 
the total Health Interview Survey 
annual sample of approximately 
12,000 segments yielded a probabil- 
ity sample of about 237,000 persons 
in 81,000 interviewed households. ~ 
Data from the two studies were 

August 1981. NCMJ 





738 
(100%) 






580 
(79%) 






H3H 
(59%) 






152 
(21%) 




55 
(7%) 



Population at Risk 



Persons Reporting New 
Illnesses During Six- 
Month Period 



Persons Who Consulted 
Family Physician 



Persons Requiring 
Consultation, Referral or 
Care by Second Physician 

Persons Hospitalized 



Fig. 1: Illness Onset and Levels of Health Care Provided During Six-Month Period. 



converted to annual rates to allow 
comparison. 

The incidence of new illness in 
the Bowman Gray sample and Na- 
tional Health Survey is similar, as is 
the frequency with which primary 
care physicians were consulted. 
However, in comparison with the 
National Health Survey data, there 
is a greater rate of consultation/ 
referral and hospitalization in our 
population. 

DISCUSSION 

All comparisons of data from our 
study with those of others must be 
done with caution. The data for our 
study were derived from respon- 
dents attending a university-based 
family practice center. There is a 
likelihood of some bias based upon 
the respondents being patients or 
family members of patients already 
receiving health care, and the loca- 
tion of the family practice center in a 
tertiary care institution setting. The 
National Health Survey inter- 
viewed individuals in a non-medical 
setting. 

The Bowman Gray data was ob- 
tained by asking patients to describe 
new illness and health care during 
the previous six months. The Na- 
tional Health Survey data recorded 
acute conditions "first noticed in 
the three-month period preceding 
the interview week that caused re- 
stricted activity, received medical 
attention, or both. The annual inci- 
dence of acute conditions (was) cal- 
culated on the basis of only those 
conditions whose onset occurred in 
the two weeks preceding the week 
of interview."'" Both studies in- 



volve data obtained by recall, rather 
than by chart review or prospective 
recording. 

The number of new illnesses re- 
ported by Bowman Gray Family 
Practice Center patient families, 
converted to yearly incidence, is 
slightly less than that reported in the 
National Health Survey, which re- 
ported acute illness during the two 
weeks before interview as opposed 
to a six-month recall period for the 
Bowman Gray study; differing 
times represent possible source of 
bias, with more accurate recall an- 
ticipated for the shorter interval. 

The rate of consultation involving 
practitioners other than the primary 
physician was much higher in this 
study than in the National Health 
Survey. Although respondents in 
our survey were patients or family 
members of patients in the Family 
Practice Center, consultation re- 
ported for various family members 
might have occurred anywhere in 
the medical center or local commu- 
nity as well as in the Family Practice 
Center. The apparent high rate of 



Table I 

Incidence of New Illness and Levels 

of Health Care Provided 





Bowman 


National 




Gray 


Health 




Study 


Survey 


Persons at Risk 


1.000 


1.000 


New Illnesses Reported, 


1.572 


1,750 


Annualized 






Family/Primary Physician 






Consulted 


1.176 


920 


Consultation. Referral or 






Other Physician 






Contacted 


412 


138 


Hospitalization Required 


149 


21 



549 



ii 



secondary/tertiary care may repre- 
sent teaching encounters involving 
various faculty members in family 
medicine as well as other spe- 
cialties. The data reported appear to 
support Fletcher's thesis regarding 
out-patient care in teaching hospi- 
tals/' 

The high rate of hospitalization in 
our population is further evidence 
that persons being treated at a 
teaching center are likely to receive 
secondary and tertiary care — in- 
cluding hospital care — rather than 
primary care. The hospital admis- 
sion rate of family members in the 
study sample was seven times that 
reported in the National Health 
Survey. The difference is certainly 
to be spuriously increased by re- 
porting differences. The hospitali- 



zation rate for the National Health 
Survey represents a minimum fig- 
ure, persons who entered the hos- 
pital immediately upon onset of the 
illness; others may have required 
hospitalization later, but no data are 
provided. Nevertheless, the strik- 
ing difference between the two 
groups is unlikely to be on the basis 
of minor differences in reporting. 

Our results when compared with 
previous studies reflect varying 
concepts of illness recorded over 
different time periods in different 
settings. Comparison of the figures 
reveal two noteworthy tendencies: 
the involvement of more than one 
physician and a relatively high hos- 
pitalization rate for families receiv- 
ing primary care in a teaching cen- 
ter. 



Acknowledgments 

The authors wish to thank Anita D. Taylor 
and Penny C. Sharp for their assistance in 
this study. 

Figure 1 was prepared by the Department 
of Audio-Visual Resources. The Bowman 
Gray School of Medicine. 

This research was supported in part by a 
grant from North Carolina United Way. 



References 

1 . White KL. Williams TF. Greenberg BG: The ecology of 
medical care. N Engl J Med 265:S85-89:. I%1. 

2. Reasons for Contact with Primary Health Care Ser- 
vices: A Model Classification. Washington, D.C.. US- 
DHEW. Office of Health Research, Statistics, and 
Technology. National Center for Health Statistics. 
1979. 

3. Petersdorf RG: Internal medicine and family practice; 
controversies, conflict, and compromise. N Engl J Med 
293:326-332, I97.V 

4. Fleming TC: The public speaks on primary care. Post- 
grad Med 66:33-.34, 1979. 

5. Fletcher SW, Fletcher RH, Pappius EM. Rudd R: A 
teaching hospital medical clinic: secondary rather than 
primary care. J Med Educ .'^4:384-391, 1979. 

6. Rabkin JG, Struenmg EL: Life events, stress, and ill- 
ness. Science 194:1013-1020, 1976. 

7. Medical Care of Acute Conditions: United Stales. 
1973-1974, Data from National Health Survey. Wash- 
ington, D.C, National Center for Health Statistics, 
USDHEW. 1979. 



If a bone be displaced at the joint, the natural and relative situation of the parts, of the 
muscles, the tendons, and the blood-vessels, are deranged, and the limb becomes useless. To 
understand exactly the state of the parts in these diseases, it was necessary, originally, in the 
first case to analyze the bones, to know that acertain substance, the phosphate of lime, was 
wanting, and to communicate this earth in greater quantities to the system, and by a proper 
mode of cure to fix it in that structure in which it is deficient: in the second case, to apply an 
apparatus, which may bring into play the power of the muscles, which favour the reduction, 
and throw out of operation those which oppose it, and thus restore the bone into its place: 
thus by a particular motion, the luxation of the thigh, at the hip, has been reduced in a 
moment, when without this happy effort of skill, it would have required immense power 
applied to the limb, with great suffering to the patient. Pathology and chemistry then 
separating the groups of facts thrown together by nature, before the mind in the one case, and 
anatomy in the other, furnishes the knowledge necessary for the cure. This system of 
analysis, which looks with an eye of scrutiny into the various masses and groups of natural 
phenomena presented in the human system, separating those which are united in the exact 
relation of cause and effect, and which the mind is so prone to view combined with others, in 
a confused and jumbled aggregate, is of the greatest importance, and it is by this process of 
separation, that science operates in conferring its benefits upon mankind. — Elements of the 
Theory and Practice of Physic, by George Gregory. M.D., with notes and additions, adapted 
to the Practice of the United States, by Nathaniel Potter, M.D., and S. Colhoun, M.D. Vol. I, 
Philadelphia, Towar & Hogan, 1829. 



550 



Vol. 42, No. 8 



il 



Acute Beryllium Lung Disease 



William F. Hooper, M.D., F.A.C.P. 



I ABSTRACT An 18-year-old male 
machinist developed acute respira- 
tory insufficiency; interstitial pneu- 
monitis was found on open lung 
biopsy. Quantitative analysis on the 
lung tissue by the Beryllium Case 
Registry indicated acute beryllium 
lung disease. Clinical and radio- 
graphic resolution occurred with ste- 
roid administration and removal 
from the work environment. Acute 
beryllium disease developed in the 
patient despite plant compliance with 
all governmental safety standards, 
suggesting that hypersensitivity 
played a role in the development of 
his disease. 



A 



INTRODUCTION 

CUTE beryllium lung disease, 
first described in the 1930s,' is 
usually an occupationally related 
tracheobronchitis or interstitial 
pneumonitis. The pathophysiology 
is poorly understood but hypersen- 
sitivity is suggested by immunologic 
studies.- The clinical picture is non- 
specific and diagnosis requires a 
history of beryllium exposure, 
.compatible histologic findings and 
iquantitative tissue analysis. This 
'case is presented because of its rar- 
ity in the non-industrial South, and 
because of its occurrence despite 
full compliance with existing safety 
standards, re-emphasizing the role 
of individual hypersensitivity. 



I Clinical Assistant Professor 

jDepartment of Medicine 

University of North Carolina School of Medicine 

Chapel Hill. N.C. 

Reprint requests to Dr. Hopper at 3 1 7 W. Wendover Avenue 

Greensboro. N.C. 2740« 



August 1981. NCMJ 



CASE REPORT 

An 18-year-old Caucasian male 
machinist was hospitalized because 
of intermittent sputum production, 
rhinitis and dyspnea with minimal 
exertion for six weeks. Two weeks 
before entry he began to have 
nosebleed, substernal pain on inspi- 
ration and diffuse abdominal pain 
with four or more diarrheal stools 
daily. As a child he had extrinsic 
asthma, which had resolved spon- 
taneously. He was involved in 
sandblasting and grinding dyes 
composed of a beryllium (29?^)-cop- 
per (98%) alloy. The plant was in- 
spected regularly by the North 
Carolina Occupational Safety and 
Health Administration and met or 
exceeded all existing standards. 

At admission he was in respira- 
tory distress with a respiratory rate 
of 35 to 45 per minute. Arterial 
blood gas measurement showed a 
partial pressure of oxygen (pOo) 41 
mm Hg; the pH 7.46: and partial 
pressure of carbon dioxide 32 mm 
Hg. With nasal oxygen at 3 liters per 
minute the pOj was 75 mm Hg. A 
diffuse infiltrate with finely nodular 
pattern throughout the lower lung 
zones was seen on chest roentgeno- 
graph (Fig. 1). Lactic dehydroge- 
nase (LDH) elevations varied be- 
tween 290 and 480 lU per liter. 
White blood count was 14,700 with 
65 polys, 13 stabs, 17 lymphs, and 5 
monos. Sputum gram stain and 
culture revealed only normal flora. 
Bronchoscopic washings for acid 
fast organisms, fungal culture and 
cytology were negative. Anti- 
nuclear antibody and monospot 



tests were negative; Westergren 
sedimentation rate was 20 mm per 
hour. 

Topical bronchodilators were 
administered via intermittent posi- 
tive pressure and aminophylline in- 
travenously. On the sixth hospital 
day thoracotomy and wedge resec- 
tion were performed: light micros- 
copy revealed usual interstitial 
pneumonitis (Fig. 2) and no signifi- 
cant birefringence was noted. Post- 
operatively cough was productive 
of purulent sputum and fever of 104° 
was observed. The administration 
of cephalothin and gentamicin and 
of methylprednisolone intraven- 
ously resulted in dramatic im- 
provement within 48 hours. Steroid 
dose was gradually decreased so 
that he was discharged on the 19th 
day taking prednisone 40 mg daily. 
While breathing room air pO^ was 
then 69.2 mm Hg. Spirometry was 
compatible with a classic restrictive 
pattern, forced vital capacity was 
1.94 liters (44% of predicted): 
forced expiratory volume in one 
second (FEV,) 1 .76 liters; and FEV, 
to FVC 90%. 

All respiratory symptoms gradu- 
ally cleared as steroids were tapered 
over several months. Five months 
after discharge spirometry and arte- 
rial gases were satisfactory, forced 
vital capacity was 3.90 liters (90% of 
predicted). FEV, 3.24 liters (83%), 
and pOo was 89.4 mm Hg on room 
air. 

The Armed Forces Institute of 
Pathology concurred with a diag- 
nosis of usual interstitial pneumo- 
nitis but recommended review of 

551 





Fig. 1: Admission chest x-ray demonstrating diffuse reticulonodular infiltrates. 



materials by the Beryllium Regis- 
try. Quantitative analysis showed 
0.028 meg of beryllium per gram of 
dried tissue, a slightly elevated 
level.* A diagnosis of acute beryl- 
lium disease was based on the triad: 
history of occupational exposure; 
compatible histologic findings; and 
increased beryllium content in the 
lung. 

DISCUSSION 

Beryllium is a metal used in 
making components for the com- 
munications, nuclear power and 
aviation industries, such as x-ray 
tube "windows,"' fission reactor 



*Sprince NL (Beryllium Case Registry) personal com- 
munication 



impeders, and re-entry cones of 
rockets. Desirable characteristics 
include light weight, increased ten- 
sile strength, x-ray transmission 
and lack of magnetic properties. '■' 
"Berylliosis, ■■ an occupational 
disease initially recognized in 1933,' 
was not established as a compensa- 
ble impairment until the 1950s."' 
Mass exposure occurred in the 
1940s with military demand for 
radiotubes and vacuum electrodes, 
and later in the fluorescent lamp in- 
dustry.^ All fluorescent lamp in- 
dustry workers who developed 
"berylliosis" had been employed 
before 1949 when beryllium use in 
these lamps was discontinued.'' 
Today the process is most often en- 
countered in plants engaged in 



fluoride and sulfate extraction of 
beryllium. -'-^ 

The United States Beryllium 
Case Registry was founded in 1952 
at the Massachusetts General Hos- 
pital to serve as a clearinghouse for 
information or beryllium associated 
disease. By 1979 fewer than 900 
cases of beryllium disease had been 
reported with fewer than 250 acute 
cases. *■' (Inclusion in the registry 
requires pathologic evidence of lung 
deposition, not simply proven ex- 
posure to beryllium.) 

Beryllium can be absorbed 
through the lung and deposited in 
the lymphatic system and bone mar- 
row. Pulmonary disease is the dom- 
inant clinical picture but ophthal- 
mologic and dermatologic man- 
ifestations are not rare.-' Because 
multisystem involvement can occur 
with or without pulmonary mani- 
festations, "beryllium disease" is 
preferred to "berylliosis" which 
implies only a pneumoconiotic pro- 
cess.'' 

The United States Atomic En- 
ergy Commission" established safe 
levels of beryllium permitted in in- 
dustry: 

• Eight-hour plant average con- 
centration . . . 

2.0 meg per cubic meter 

• Single acute instantaneous ex- 
posure . . . 

25 meg per cubic meter 

• Average monthly neighbor- 
hood concentration . . . 

0.01 meg per cubic meter 

Intensity and duration of expo- 
sure appear more important than 
the specific active beryllium com- 
pounds encountered."' Exposure 
may be tangential or remote as in 
cases of people living near a beryl- 
lium plant or among wives handling 
the uniforms of workers.** Only a 
small percentage of the population 
at risk develops clinical disease and 
host reactivity appears to play a sig- 
nificant role.' •' The pathophysiol- 
ogy is poorly understood but im- 
mune studies involving macrophage 
inhibiting factor and blast transfor- 
mation and response to steroids 
suggest hypersensitivity phenom- 
ena.-' 



•Sprince NL (Beryllium Case Registry) personal com- 
munication 



552 



Vol. 42. No. 8 



Acute beryllium disease usually 
presents as a chemical pneumonitis 
or tracheobronchitis. Upper airway 
inflammation can result in subster- 
nal pain, epistaxis. ulceration and 
even septal perforation. Cough is 
typically nonproductive; sputum 
production and elevated tempera- 
ture suggest superimposed infec- 
tion. Physical findings are usually 
limited to tachycardia, rales, and 
tachypnea although cyanosis can 
occur.-'"' Radiographically any pat- 
tern can be encountered, from 
mildly accentuated reticular mark- 
ings to frank pulmonary edema. 
Laboratory studies are non- 
diagnostic: leukocytosis suggests 
superimposed infections. Beryllium 
is found in urine of most patients 
with acute beryllium disease but in 
no greater amounts than in urine of 
healthy individuals exposed. The 
concentration will vary daily and 
often may approach zero. Urinary 
quantitation, however, may be of 
great value in demonstrating ex- 
posure to beryllium.' Histologically 
the pulmonary interstitium is infil- 
trated by lymphocytes and plasma 
cells in moderate numbers. Cells 
lining the alveoli may be multi- 
nucleated and a desquamation can 
be seen with small quantities of 
protein deposited intraalveolarly as 
hyaline membranes. Granulomas 
and inclusions are not seen, in con- 
trast to chronic beryllium disease.'' 

Chemical extraction permits de- 
tection of as little as 0.002 micra of 
beryllium per gram of dried tissue 
but does not distinguish between 
inert beryllium silicate and active 
compounds.'^ Less than 0.020 meg 
per gram dried tissue is considered 
normal; levels of 0.028 (this patient) 
and 0.033 are "slightly" and "mod- 
erately" elevated.** In one series of 
six fatal cases of acute beryllium 
disease, lung concentrations varied 
from 0.004 meg to 1.8 meg per 
gram.' The concentration of beryl- 
lium found in lung tissue does not 
correlate with length of occupa- 
itional exposure or duration of ill- 
jness.^ 

j Beryllium lung disease does not 
usually demonstrate an orderly pro- 
gression from acute to chronic dis- 
ease, previous acute attacks having 



August 1981. NCMJ 



^'^-^ 







i 



A ■ 



Fig. 2: Open lung biopsy demonstrating usual interstitial pneumonitis. 




been reported in less than 109f of 
cases of chronic beryllium lung dis- 
ease.' Fewer than a dozen cases of 
fatal acute beryllium disease are in- 
cluded in the Registry, and most in- 
dividuals with acute disease recover 
without sequellae. In fatal cases the 
disease ran its course in two to 10 
weeks, averaging one month. ^ The 
interval between acute attacks and 
histologic findings of chronic dis- 
ease has varied from 13 months to 
17 years and the transition is sub- 
tle."' 

Diagnosis of acute beryllium dis- 
ease while symptoms are mild and 
reversible is difficult because it 
mimics nonspecific pneumonitis. 
Most workers will not get into diffi- 
culty if the concentration of beryl- 
lium in the atmosphere does not ex- 
ceed 25 meg per cubic millimeter. 
Respirators are not usually neces- 
sary if the environmental concen- 
trations of beryllium are regularly 
determined and found to be within 
acceptable range. ^ At present it is 



not possible to identify hypersen- 
sitive individuals readily and con- 
tinued surveillance is necessary 
despite compliance with OSHA 
standards. 

Patients with acute beryllium dis- 
ease have been given adrenal 
steroids but their efficacy is un- 
proven. Isolated instances of spon- 
taneous remission have been re- 
ported.'' 



References 

1 . Fabroni SM: Patalogia pulmonare da polveri di berillio. 
Med Lavoro 26:297. 1935. 

2. Prince CD. Pugh A. Pioli EM. Williams WJ: Beryllium 
macrophage migration inhibition test. Ann NY Acad Sci 
278:2(M, 1976. 

3. Seaton A. Morgan WKC: Occupational Lung Disease. 
Philadelphia. Saunders Company, 1975. pp 223-231. 

4. Reeves.^L; Beryllium in the environment. Clin To.xicol 
10:37-48. 1977. 

5. Freiman DG. Hardy HL: Beryllium disease. The re- 
lationship of pulmonary pathology to clinical course and 
prognosis based on a study of 130 cases from the U.S. 
Berylhum Case Registry. Hum Pathol 1:25-44. 1970. 

6. Walkley J A: Study of the Morin method for the deter- 
mination of beryllium in air samples. Am Ind Hgy J 
Assoc J 23:241-245. 1959. 

7. Dutra FR, Cholak J. Hubbard DM: The value of beryl- 
lium determination in the diagnosis of berylliosis. Am J 
Clin Path 19: 229-234, 1949. 

8. Mark GJ. Monroe CB, Razemi H: Mixed pneumoconi- 
osis; silicosis, asbestosis, talcosis, and berylliosis. 
Chest 75:726-727. 1979. 

9. Sprince NL. Kanarek DJ. Weber AL, Chamberlin Rl, 
Kazemi H: Reversible respiratory disease in beryllium 
workers. Am Rev Respir Dis 117:1011-1017. 1978. 



553 



Special Article 

Medical Care in North Carolina Jails 



Nancy Taylor, R.N.*, and Carleen Massey, R.N. 



NORTH Carolina law makes 
sheriffs and jailers responsible 
for seeing that each prisoner re- 
ceives adequate medical care. The 
statutes require each county that 
operates a jail to pay for "emer- 
gency medical services" and to de- 
velop a "plan" for medical care to 
"protect the health and welfare" 
of prisoners, to avoid the spread of 
contagious diseases, and to pro- 
vide for detecting, examining and 
treating prisoners who are infected 
with tuberculosis or venereal dis- 
ease. t This plan must be developed 
in consultation' with the sheriff, the 
county physician, the district health 
director, and the local medical soci- 
ety and must finally be approved by 
the local health director. 

Although North Carolina law 
emphasizes emergency medical 
care, the jailer, the sheriff and the 
county will be better protected by 
also providing regular (non-emer- 
gency) care. This approach may 
actually reduce total medical care 
cost and will not usually increase it. 

In 1975 the American Medical 
Association (AM A) received a grant 
from the federal Law Enforcement 
Assistance Administration (LEAA) 



•Formerly with the North Carolina Medical Society as the 
State Project Coordinator for the AM A jail health project. 
"'State Project Coordinator for the AMAjaiJ health project. 
Repnnted from Popular Government magazine. Fall. 1980 
^'Copynght 1980. Institute of Government. University of 
North Carolina. Chapel Hill, N.C. 



tN.C. Gen. Stat. SS LS3A-2:4(b). -225. 



to initiate a program for improving 
health care services in jails. The 
major accomplishments of the pro- 
gram include: developing alternate 
approaches to jail health services 
("model systems" such as contract 
physician/staff nurse or county 
health physician/county health 
nurse), establishing a clearinghouse 
to gather and dispense information 
about jail health care (18 AMA pub- 
lications have been sent to North 
Carolina's project jails), develop- 
ing and implementing the AMA 
Standards for Health Services in 
Jails, and establishing an accredita- 
tion program for medical services in 
jails. 

IMPROVING HEALTH CARE 
STANDARDS 

In 1972 the AMA conducted a 
national survey to evaluate medical 
care in jails. The 1,159 question- 
naires that were returned revealed 
a gross inadequacy of health and 
medical services throughout the 
country. In addition, some suc- 
cessful lawsuits in behalf of prison- 
ers focused national attention on the 
deplorable conditions in jails: ( 1 ) the 
only medical services in 66% of the 
jails were first-aid facilities. (2) phy- 
sicians were available on a regularly 
scheduled basis in only 38% of the 
jails, (3) no specific physician was 
designated "on call" to provide 
medical care in 32% of the jails, and 
(4) health care delivery in jails con- 
sisted mainly of treatment in emer- 



gency rooms and physicians' offices 
for acute and emergency cases. 

AMA Standards. Federal courts 
have held that adequate medical 
care in jails is required by the Eighth 
and Fourteenth amendments to the 
United States Constitution. There- 
fore medical care must be consid- 
ered an integral part of total jail 
administration. An organized, effi- 
cient medical care system in jails is 
possible through close cooperation 
among the medical staff, jail per- 
sonnel, and county administration. 
The most effective means for im- 
plementing a good system is to 
adapt the AMA health care stan- 
dards, which are acknowledged 
criteria for measuring the quality 
and quantity of health care delivery 
systems. The AMA Standards were 
developed by task forces that were 
approved by the AMA Board of 
Trustees and worked out under the 
supervision of the AMA Advisory 
Committee to improve medical care 
and health services in correctional 
institutions. Several hundred sher- 
iffs, jail administrators, and health 
care providers made substantial 
contributions to the standards, 
which were subjected later to test- 
ing by pilot-project jails and found 
to be realistic and achievable. They 
define "adequate medical care" as 
required by federal and state courts. 

The first edition of the AMA 
Standards addressed 42 issues and 
was approved by the National 
Sheriffs' Association, the American 



554 



Vol. 42, No. 8 



Correctional Association, the Com- 
mission on Accreditation for Cor- 
rections, and tiie AMA House of 
Delegates. The most recent edition 
(69 standards) includes detailed 
criteria for care of chemical depen- 
dency and psychiatric problems. 
Chemical dependency refers to the 
condition of individuals who are 
physiologically and/or psychologi- 
cally dependent on alcohol, opium 
derivatives and synthetic drugs with 
morphine-like properties (opioids), 
stimulants and depressants. These 
additional standards are extremely 
important, since national criminal 
justice service agencies report that 
one of their major problems is how 
to deal with mentally ill and chemi- 
cally dependent people who are 
detained in jail. 

These AMA Standards empha- 
size bringing medical resources into 
the jail for routine care and trans- 
• ferring inmates with extraordinary 
needs. They address the following 
aspects of medical, psychiatric, 
dental care and health services: 

1. Administrative — designating 
a health authority to oversee 
medical care services. 

2. Personnel — providing an ade- 
quate number of health-trained 
correctional officers. 

3. Care and treatment — provid- 
ing regularly scheduled sick 
call and health appraisals on all 
inmates. 

4. Pharmaceuticals — adhering 
to state and federal laws and 
the regulations and require- 
ments for controlling medica- 
tion; providing procedures for 
dispensing, administering and 
distributing medication. 

5. Health records — assuring 
that appropriate form, format, 
storage, transfer and confi- 
dentiality of health records is 
maintained. 

6. Medical legal issues — assur- 
ing that an inmate's legal right 
to informed consent and right 
to refuse treatment is honored. 

Ninety jails, ranging in size from 
small to large, have been accredited 
under the AMA Standards. The 
majority are small and medium 
sized, with average daily popula- 
tions ranging from 15 to 1,300 in- 
mates. To achieve two-year AMA 

August 1981. NCMJ 



accreditation, jails must comply 
with 23 "essential" standards and 
85% of the remaining applicable 
standards. One-year accreditation 
requires that jails comply with 23 
"essential" standards and 70% of 
the remaining applicable standards. 
The accreditation is carried out by a 
trained survey team composed of 
the state project coordinator, a phy- 
sician and AMA representatives. 
The team makes an on-site visit and 
conducts a comprehensive survey 
to measure compliance with each 
standard: it also interviews inmates, 
the "responsible" physician, the 
jail nurse, the dietitian and others. 
This survey is returned to the AMA 
for staff review and analysis: an ac- 
creditation advisory group then 
conducts its review and gives a final 
recommendation. The AMA sends 
the jail a statement of the results. 
Once accredited, the jail must con- 
tinue to comply with the standards 
to maintain that accreditation. The 
primary benefit of accreditation to a 
jail is the professional and public 
recognition of good performance — 
i.e., the jail's health care delivery 
system is found by organized medi- 
cine to be "adequate" in terms of 
the medical care and health services 
it offers. 

Results of implementing AMA 
Standards. Implementing the AMA 
Standards can reduce ultimate 
health care costs. A sample study 
of ten jails in a northeastern state, 
a mid-Atlantic state, and two mid- 
western states reveals that one- 
third were spending less money 
overall by meeting the standards 
than before the implementation, 
one-third were spending more, and 
one-third were spending the same 
amount for health care. 

Providing regular "sick call" is 
often no more expensive than the 
cost of an emergency room or phy- 
sician's office visit. Sick call de- 
creases the manpower hours for 
transportation and treatment; it also 
decreases the risk of escape by the 
inmate. Costs also have been con- 
trolled by using existing resources 
— such as county health depart- 
ments — to provide nursing ser- 
vices, which are under the supervi- 
sion of a physician, for the majority 
of sick-call complaints. Early iden- 



tification and treatment of health 
problems (through "receiving 
screening" and "health apprais- 
als") also helps avoid extraordinary 
expenditures. 

Compliance with the standards 
may imply additional health care 
costs, but not all standards require 
dollar outlays to assure conformity. 
Whether implementing the AMA 
Standards will result in additional 
costs can be determined only on a 
jail-by-jail basis when all aspects of 
health care costs, direct and indi- 
rect, have been taken into account. 
While the LEAA provides funding 
for the AMA and state medical soci- 
ety to administer the program, the 
jails must absorb any costs for 
whatever changes they make in 
their health care delivery system. 

NORTH CAROLINA'S 
PARTICIPATION 

The North Carolina Medical So- 
ciety has participated in the Jail 
Health Project since 1978. Twen- 
ty-two other state medical societies 
also participate in the program. The 
fact that North Carolina was se- 
lected is not a reflection on the 
quality of jail health care in this state 
but rather reflects the state medical 
sociely's interest in this matter. The 
society has one fuUtime staff mem- 
ber, the state project coordinator, 
whose responsibilities include pro- 
viding technical assistance for im- 
plementing AMA Standards to the 
jails that are included in this project 
This staff member is in close touch 
with the AMA, makes periodic re- 
ports of progress, and receives 
AMA technical expertise. The state 
medical society has a Jail Project 
Advisory Committee composed of 
physicians and consultants who 
have a special interest in jail health 
care. This committee serves in an 
advisory capacity to the state proj- 
ect coordinator and oversees the 
project in North Carolina. The ten 
participating jails are in Bun- 
combe, Cabarrus. Cumberland, 
Edgecombe, Harnett, New Han- 
over, Orange, Pitt, Sampson and 
Wake Counties. They were selected 
on the basis of their size and geo- 
graphic location, the status of their 
health care delivery, and their inter- 
est in the project. The jails receive 

555 



technical help in establishing a sys- 
tematic, efficient system for ade- 
quate medical care delivery. 

When a jail begins participating in 
the project, the sheriff signs a writ- 
ten agreement with a health author- 
ity that will be responsible for health 
care services within the jail. In most 
cases the health authority is a phy- 
sician; if the position is filled by 
someone other than a physician the 
AMA Standards specify that a phy- 
sician must be on call who will be 
responsible for making final judg- 
ments about diagnoses and treat- 
ment. The State Medical Society 
through the county medical soci- 
eties has helped to find such a 
physician for those jails that have 
had difficulty in finding one. (It 
should be noted that having an 
available physician does not insu- 
late the jail staff and the sheriff from 
inclusion in a health-related law- 
suit.) 

Many jails in North Carolina do 
not have written rules of procedure 
nor maintain adequate health rec- 
ords. Even though jails may have 
established procedures, the ab- 
sence of formal rules causes lack of 
continuity in carrying out policies 
and procedures. One of the AMA 
"essential" standards requires a 
manual of written policies and de- 
fined procedures. The project jails 
are in the process of adopting a 
medical policy and procedure man- 
ual developed by the Georgia Medi- 
cal Society to meet their own needs. 
Using AMA sample forms, these 
jails are developing a uniform sys- 
tem of health recordation, which 
must be accurate and confidential. 
Basic information in these records 
includes: the completed receiving 
screening form (Fig. 1); health ap- 
praisal data forms; all findings, 
diagnoses, treatments, disposi- 
tions; prescribed medications and 
their administration; laboratory, 
x-ray, and diagnostic studies; sig- 
nature and title of documentor; con- 
sent and refusal forms; release-of- 
information forms: place, date and 
time of health encounters; dis- 
charge summary of hospitaliza- 
tions; and reports on dental, psy- 
chiatric and other treatment. 

Additional medical education for 
jailers is another significant need. 

556 



The AMA Standards require that 
at a minimum inmates always be 
within sight or sound of at least one 
health-trained correctional officer 
who has training at least equivalent 
to a basic first-aid course. At least 
one officer per shift should be 
trained in basic cardiopulmonary 
resuscitation (CPR) and in recog- 
nizing common illnesses of inmates. 
The AMA Standards also require 
that appropriate jail personnel re- 
ceive training in administering 
medications, in recognizing mental 
deficiency and chemical depen- 
dency, and in dealing with health 
emergencies. Jailers can receive 
first-aid and CPR training locally 
through the American Red Cross, 
community colleges, medical 
schools and the American Heart 
Association. 

To help trainjailers in health care, 
the North Carolina Medical Society 
sponsored a two-day LEA A-funded 
training session in Raleigh on April 
8-9, 1980. Individual sessions fo- 
cused on receiving screening; rec- 
ognizing signs of ill health and 
emergencies; administering medi- 
cations; following medical orders; 
dealing with mental illness and defi- 
ciency, alcoholism and drug abuse; 
and legal aspects of medical care in 
jails. Each of the 40 jailers who at- 
tended the training session received 
a manual on these subjects and also 
a certificate of achievement. 

Historically jails have been a 
neglected part of the criminal justice 
system. Over 200,000 people are in 
jails in this country. The way these 
inmates are treated in jail may affect 
their attitudes and perceptions of 
society when they are released. One 
simple procedure that may have a 
positive effect on both inmates and 
jail personnel is "receiving screen- 
ing." Receiving screening is an or- 
ganized way to observe and inter- 
view each new inmate when he or 
she is booked. The booking officer 
completes the screening form by 
observing the inmate and asking 
him questions about his health. The 
following are some of the possible 
benefits of receiving screening: 

1. Identifying an inmate's need 
for immediate medical atten- 
tion — e.g.. head injury, chest 



pain that might indicate a car- 
diac condition, etc. 

2. Identifying a chronic disease 
that requires ongoing treat- 
ment — e.g., diabetes mel- 
litus, epilepsy, etc. 

3. Providing an opportunity to 
observe signs and symptoms 
of alcohol or drug abuse, over- 
dose, or withdrawal. 

4. Protecting against legal liabil- 
ity (may identify an injury that 
an inmate received before he 
was confined to jail that he 
might later claim he received 
in the jail). 

5. Identifying a communicable 
disease, such as tuberculosis, 
and taking measures to pre- 
vent the disease from spread- 
ing to staff and other inmates. 

6. Providing an opportunity to 
observe a mental or emotional 
condition, such as suicidal 
tendency. 

7. Showing the jail's interest in 
assuring inmates' well-being. 

8. Indicating to the inmate that 
someone cares about him and 
thus creating a more positive 
jail atmosphere. 

If an abnormality is detected 
during the receiving screening pro- 
cess, the jail staff should refer the 
inmate to the appropriate health 
care personnel for follow-up. 

The North Carolina Medical So- 
ciety provides technical help to the 
jails that are participating in the jail 
health project in obtaining appro- 
priate health care personnel to con- 
duct health appraisals and sick call 
in the jail. The AMA Standards re- 
quire that an appraisal be performed 
on each inmate before the four- 
teenth day of his confinement. 
Health appraisal data include health 
history, physical examination and 
screening for communicable dis- 
ease. For those inmates who have 
received a health appraisal within 90 
days, a new appraisal is required 
only if the physician or his designate 
feels it is necessary. 

The state society has enlisted the 
assistance of local medical soci- 
eties, health departments and vari- 
ous community and statewide agen- 
cies to help the jails upgrade their 
medical care delivery systems. 
Some positive effects from this pro- 

VOL. 42. No. 8 



Receiving Screening Form 



DATE_ 



NAME- 



SEX- 



D.O.B. 



TIME- 



INMATE NO. 



OFFICER OR PHYSICIAN- 



Booking Officer's Visual Opinion 

1 . Is the inmate conscious? 

2. Does the new inmate have obvious pain or bleeding or other symptoms 
suggesting need for emergency service? 

3. Are there visible signs of trauma or illness requiring immediate emer- 
gency or doctor's care? 

4. Is there obvious fever, swollen lymph nodes, jaundice or other evidence 
of infection which might spread through the jail? 

5. Is the skin in good condition and free of vermin? 

6 Does the inmate appear to be under the influence of alcohol? 

7. Does the inmate appear to be under the inMi.ience of barbiturates, heroin 
or any other drugs? 

8. Are there any visible signs of alcohol/drug withdrawal symptoms? 

9. Does the inmate's behavior suggest the risk of suicide? 
Does the inmate's behavior suggest the risk of assault to staff or other 
inmates? 

Is the inmate carrying medication or does the inmate report being on 
medication which should be continuously administered or available? 



10 



11 



YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 



Officer-Inmate Questionnaire 

12. Are you presently taking medication for diabetes, heart disease, 
seizures, arthritis, asthma, ulcers, high blood pressure, or psychiatric 
disorder? Circle condition. 

13. Do you have a special diet prescribed by a physician? 
Type 

14. Do you have history of venereal disease or abnormal discharge? 

15. Have you recently been hospitalized or recently seen a medical or 
psychiatric doctor for any illness? 

16. Are you allergic to any medication? 

17. Have you fainted recently or had a recent head injury? 

18. Do you have epilepsy? 

19. Do you have a history of tuberculosis? 

20. Do you have diabetes? 

21 . Do you have hepatitis? 

22. If female, are you pregnant? 

23. Are you currently on birth control pills? 

24. Have you recently delivered? 

25. Do you have a painful dental condition? 

26. Do you have any other medical problem we should know about? 

REMARKS: 



3. 

4. 



(A copy of this form is included in the inmate's medic:al record) 



YES NO 



YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 


YES 


NO 



August 1981. NCMJ 



557 



gram have been evident, and the 
jails have shown considerable in- 
terest in improving the health care 
of inmates. The chief jailer of one 
of the North Carolina participating 
jails commented: 
I personally feel the AMA Proj- 
ect is fulfilling its goals by up- 
grading medical care within the 
jail and detention facilities. Stan- 
dards of training for officers has 
improved, which permits the of- 
ficers to have a better under- 
standing of the medical needs of 
the inmate. This training is a 
priority of the Medical Society 
staff in Raleigh, which reflects 
their concern for the health de- 
livery system within the jail and 
detention facility. The profes- 



sional skills of the staff in re- 
spect to better health care for 
inmates have enhanced our abil- 
ity to assure the inmate receives 
adequate medical treatment dur- 
ing incarceration in the Cumber- 
land County Jail. Close coop- 
eration and coordinated efforts 
between the State Society staff 
and the jail facility will assure 
the inmate of continued adequate 
medical care during incarcera- 
tion. 
According to the AMA Jail 
Health Program director. North 
Carolina's progress in assuring ade- 
quate health care in jail has been 
good. Health care for inmates has 
improved overall, and some jails are 
working toward accreditation. The 



state medical society will continue 
to provide technical assistance to 
ten jails in the state. When a jail 
becomes accredited or makes suffi- 
cient progress so that the society's 
assistance is no longer needed, the 
society will solicit new jails as par- 
ticipants. As time permits, it will 
also provide technical assistance on 
a limited basis to nonparticipating 
jails. 

Rererences 

American Medical Association. Standards for Health 
Services in Jails. Chicago. 111.: AMA, July 1979. 

Medical Care in U.S. Jails. Chicago, III.: AMA, 1972. 

Anno, B. Jaye. and Lang, Allen H. Final Evaluation Re- 
port of the Ameincan Medical Association's Program to 
Improve Health Care in Jails (Year Three). Silver Spring, 
Md,: B- Jaye Anno Assoc, June 1979. 

Ten Jail Case Study and .Analysis. Silver Spring, Md.: 
B. Jaye Anno Assoc. June 1979. 

Clarke. Stevens H. North Carolina Statutes Pertaining to 
Jails, Chapel Hill. N.C: Institute of Government, 1978. 

Department of Governmental Affairs, University of Wis- 
consin Extension. Training of Jailers in Receiving Screening 
and Health Education Manual for Students. Madison. Wis.; 
Univ. of Wis. Extension, March 1978. 



The object of the science of medicine is the prevention and the cure of diseases. Though the 
noxious agents which surround us are numerous, yet nature supplies, in some measure, the 
means of preventing and curing their bad effects. Thus the exhalations from putrefying 
animal matter produce fever; and their disagreeable and horrible stench is a sufficient 
warning to avoid them: if fever has taken place from this cause, the delirium, and the morbid 
heat of skin which attend it, inspire an instinctive disposition to plunge into cold water; and 
the relief produced by it is immediate, and generally certain. 

The power of nature alone, though great, is not, however, always sufficient, either to 
discover these noxious agents, or to remove the diseases produced by them: thus the 
miasmata from vegetables, though equally baneful with those from animal matter, often give 
no warning by their smell, and destroy without their danger being anticipated. This is true 
with regard to many other noxious agents: thus sudden exposure to mephitic airs in de- 
scending below the surface of the earth, takes away life; and no instinct, no sense, warn us of 
our danger. We therefore require other aids than those of nature alone, in avoiding the causes 
of diseases; and it is the province of the science of medicine to supply them, by a cautious 
examination of the properties of bodies around us. 

Though diseases are often relieved without the assistance of art, yet it is well known that 
many processes undertaken by nature to repair any injury, are often too violent, and destroy 
life. Here then art assists; and in doing so, the properties and nature of the system, as also 
those of external bodies, must be studied, to discover their effects upon it. The mind and the 
senses, accordingly, are the instruments by which this end is effected. In their application for 
the purposes of discovery to the world around us, great errors have been committed, and 
much useful time and labour has been lost, in their direction to the practical duties of our 
profession. — Elements of the Theory and Practice of Physic, by George Gregory, M.D., 
with notes and additions, adapted to the Practice of the United States, by Nathaniel Potter, 
M.D.. and S. Colhoun, M.D. Vol. I, Philadelphia, Towar & Hogan, 1829. 



558 



Vol. 42, No. 8 



I 



YOUR SUPPORT IS NEEDED 
CONTRIBUTE TO WORTHY PROJECTS 

TAX DEDUCTIBLE 



THE NORTH CAROLINA MEDICAL SOCIETY FOUNDATION, INC. was created in 1966 
originally to receive funds for the construction of a new headquarters 
office in Raleigh. However, when other methods of financing a permanent 
building were devised, the role of the Foundation was changed. This 
change permitted the N. C. Medical Society Foundation to be approved as 
a charitable institution empowered to receive TAX EXEMPT contributions 
for the purposes of education and scientific advancement. The North 
Carolina Medical Society Foundation, Inc. has a 501(c) (3) letter from 
the Internal Revenue Service. 



Among the contributions made to the Foundation since its inception have 
been: 

— The Forsyth-Stokes Medical Auxiliary Benevolent and Educational 
Fund in 1971, and 

— the assets of the Joseph Ward Hooper, Sr. , Trust which were 
transferred to the Foundation in 1976. 

While these examples of group contributions have been greatly appreciated, 
your individual support is badly needed. Today, after more than 12 years, 
the resources of the Foundation are still quite limited. As the financial 
resources grow, the opportunities to use these funds for worthy projects 
will increase and all of us will benefit by its success. 



At this time the Foundation is prepared to: 

— serve as a custodian of contributions designated by groups for 
special projects, 

— receive direct contributions and donations of stock or general 
capital certificates of the Medical Liability Mutual Insurance 
Company, all TAX EXEMPT , and to 

— accept from wills bequests which, properly defined, would not 
be taxable to the estate of the donor. 



Please make your tax exempt contribution payable to; 
MEDICAL SOCIETY FOUNDATION, INC. and mail to: 

N. C. Medical Society Foundation 

P. 0. Box 27167 

Raleigh, N. C. 27611 



THE NORTH CAROLINA 



Toxic Encounters of the Dangerous Kind—] 
More On Speeding 



Because phenylpropanolamine is avail- 
able over-the-counter, it can be found in 
many preparations. It is a staple in cold 
tablets and is also offered as an appetite 
suppressant.' The PDR~ lists over 100 
compounds containing the drug and the 
Handbook of Non-Prescription Drugs, ^ 
39 not found in the PDR. These are given 
below and 23 others found on shelves and 
counters of drugstores and supermarkets 
listed. 

Easily Available Drugs Containing 
Phenylpropanolamine 

PDR~ 

Anatuss Tablets & Syrup 

Anatuss Tablets & Syrup w/Codeine 

Anorexin Capsules 

Anorexin One-Span Capsules 

Appedrine, Maximum Strength 

Bayer Children's Cold Tablets 

Bayer Cough Syrup for Children 

Brocon C. R. Tablets 

Brocon Chewable Tablets 

Brophentapp T.D. Tablets 

Cenadex 

Codimal Expectorant 

Comtrex 

Conex 

Conex with Codeine 

Congespirin Liquid Cold Medicine 

Control Capsules 

Coricidin Children's Cough Syrup 

Coricidin Cough Syrup 

Coricidin "D" Decongestant Tablets 

Coricidin Demilets for Children 

Coricidin Sinus Headache Tablets 

Coryban-D Capsules 

Daycare Daytime Colds Medicine-Liquid 

Daycare Multi-Symptom colds 

Decon-Aid TR Capsules 

Decon-Tuss TR Capsules 

Dehist 

Deprohist Expectorant w/Codeine 

Dexatrim Capsules 

Dexatrim Capsules, Extra Strength 

Dextrotussin Syrup 

Dimetane Expectorant 

Dimetane Expectorant-DC 

Dimetapp Elixir 

Dimetapp Extentabs 

Dorcol Pediatric Cough Syrup 

Entex Capsules & Liquid 



Entex LA Tablets 

4-Way Cold Tablets 

Fiogesic Tablets 

Formula 44D Decongestant Cough 

Mixture 
Histabid Duracap 
Histalet Forte Tablets 
Histatapp Elixir 
Histatapp T.D. Tablets 
Hycomine Pediatric Syrup 
Hycomine Syrup 
Kronohist Kronocaps 
Leder-BP 
Leder-CC Sequels 
Leder-CPl Sequels 
Naldecon 

Naldecon-DX Pediatric Syrup 
Naldecon-EX Pediatric Drops 
Napril Plateau Caps 
Nilcol Tablets & Elixir 
Nolamine Tablets 
Norel Plus Capsules 
Norel Plus Injection 
Novahistine DH 
Novahistine Expectorant 
Obestat Long Acting Capsules 
Omade Spansule Capsules 
Omade 2 Liquid for Children 
Phenatapp Extend Tablets 
Phenylpropanolamine HCl T.D. 

Capsules 
Poly-Histine Expectorant, Plain 
Poly-Histine Expectorant with Codeine 
Poly-Histine-D Capsules 
Poly-Histine-D Elixir 
Prolamine Capsules, Super Strength 
Protid 

Purebrom Compound Elixir 
Purebrom Compound Tablets 
Resaid T.D. Capsules 
Rhindecon Capsules 
Rhinedecon-G Capsules 
Rhinex D.Lay 
Rhinolar Capsules 
Rhinolar-EX Capsules 
Rhinolar-EX 12 Capsules 
Robitussin-CF 
Ru-Tuss Expectorant 
Ru-Tuss Plain 
Ru-Tuss Tablets 
Ru-Tuss with Hydrocodone 
S-T Forte Syrup & Sugar-Free 
Sine-Aid Sinus Headache Tablets 



I 



I 



560 



Vol. 42. No. 8 



Sinubid 

Sinulin Tablets 

Triaminic Expectorant 

Triaminic Expectorant DH 

Triaminic Expectorant w/Codeine 

Triaminic Preparations 

Triaminic Syrup 

Triaminic-DM Cough Formula 

Triaminicol Decongestant Cough Syrup 

Tusquelin 

Tuss-Ornade 

Vicks Formula 44D Decongestant Cough 

Mixture 
Voxin-PG 

Handbook^ 

Allerest 

Allergesic 

Apcohist Allergy Tablets 

Atussin DM Expectorant 

Atussin Expectorant 

Bayer Decongestant 

Breacol 

C3 Capsules 

Covanamine 

Covangesic 

Diet-Trim 

Endecon 

Extendac 

Grapefruit Diet Plan with Diadax Tablets 

Ginsopan 

Halls 

Lanatuss 

Naldetuss 

Nature's Trim Plan with Diadax Tablets 

Nazac Timed — Disintegration 

Decongestant 
Neophiban 
Odrinex Tablets 
Ornacol Capsules and Liquid 
Prolamine Capsules 
Rhinidrin 
Romilar III 

Ryna-Tussadine Expectorant 
Sinurex 
Sinutab 
Soltice 
Spantac 
Spantrol Capsules 



St. Joseph Cold Tablets for Children 

Super Anahist 

Timed Cold Capsules 

Ursinus 

Vasominic 

Ventilade 

Vita-Slim Capsules 

Others 

Alka-Seltzer Plus Cold Medicine 

CCP Cough and Cold Tablets 

C3 Cold Cough Capsules 

Children's Hold 

Codexin Capsules 

Contac Capsules 

Contac Jr. Children's Cold Medicine 

Dex-A-Diet Capsules 

Dietac Capsules/Drops/Capsules 

Dristan 

Decongestant/ Antihistamine/ Analgesic 

Capsules 
D-Sinus Capsules 
E-Z Trim Capsules 
Ornex Capsules 
P.V.M. Appetite Control 

Capsules/Tablets 
Sine-Off Extra Strength Sinus Medicine 
Sine-Off Sinus Medicine 
Sinutab Tablets 
Sinutab II Tablets 

Sinutab Extra Strength Capsule Formula 
Sinutab Extra Strength Tablets 
Sucrets Cold Decongestant Formula 
Tussagesic Tablets 
Tussagesic Suspension 

Ronald B. Mack, M.D. 
Department of Pediatrics 
Bowman Gray School of Medicine 

of Wake Forest University 
Winston-Salem, N.C., and 
Chairman, Committee on Accidents 

and Poison Prevention 
North Carolina Chapter of the 

American Academy of Pediatrics 

References 

1. Mack RB: Are your patients speeding? NC Med J 42: 489. 1981. 

2. Physicians' Desk Reference. 35th ed. Medical Economics Co.. 
1981. 

3. Handbook of Nonprescription Drugs. 5th ed. American Phar- 
maceutical Association. 1977. 



kuGusT 1981, NCMJ 



561 




University Microfilms International 



Please send additional information for 
Name 



( name of publication) 



Institution 

Street 

City 

State 



Zip. 



300 North Zeeb Road 

Dept. PR. 

Ann Arbor, Mi. 48106 

U.S.A. 



30-32 Mortimer Street 
Dept. PR. 
London WIN 7RA 
England 



Pioneers in Medicine 
For the Family 

BOOTS PHARAAACEUTICALS, INC. 

Operatins in the U.S. since 1977, Boots is a world-wide leader in 
pharmaceutical research and manufacture. Boots has directed its efforts 
toward providins products useful in the practice of family medicine. 

Some of our better known products are Lopurin™ , Ru-Tuss® and 
Ru-Vert® . This advertisement hishlishts four other products particularly 
useful for the family 



F-E-P CREME' ♦ SU-TON* ♦ TWIN-r ♦ TWIN-K-CI 




For the Majority of 
Steroid-Responsive Dermatoses* 
Seen in Family Practice 

f-E-P CRtME' 

(lodochlorhydroxyquin—PramoxineHCI— Hydrocortisone) 

Tlie 4 in 1 Corticosteroid Cream 

Anti-inflammatory, antifunsal, antibacterial actions, 
and, uniquely, a topical anesthetic for immediate 
relief of the itching or burning that frequently 
accompanies skin problems. One size CA ounce), 
one strength for ease of prescription. 

•This dru3 has been evaluated as possibly effective for these indications. 
See prescribins information on last pase of this advertisennent- 



For the Geriatric Patient 

SU-TON 

Liquid Tonic 

A pleasant tasting prescription tonic containins 
iron, vitamins, minerals, an analeptic and 18% 
alcohol. Ideal for those who may benefit from 
vitamin deficiency prevention. Just one table- 
spoon before each meal. i. 

Each 45 ml (3 tablespoonfuls) contains: 

Pentylenetetrazol 30 rr 

Niacin 50 T 

Vitamin B-1 10 ir 

Vitamin B-2 5ti 

Vitamin B-6 It 

Vitamin B-12 3 mt 

Choline : lOOn 

Inositol 5O5, 

Manganese (as Manganese Sulfate) 

Magnesium (as Magnesium Sulfate) 

Zinc (as Zinc Sulfate) 

Iron (as Feme Pyrophosphate, Soluble). 

Alcohol 

See prescribing information on last page of this advertisement. 



i 




NPotassium Supplementation 
proved Compliance . . * 

ml supplies 20 mEq of potassium ions as a combination of potassium 
e and potassium citrate in a sorbitol and saccharin solution. 

pod tasting potassium supplement 

Igned for prophylactic and therapeutic use 

h diuretics and adrenocorticoids. 

3sant taste and convenient dosage aid 

ient compliance. 

: organic salt of potassium can be given as a 

jid without producing significant gastric 

iptoms and v^ithout an untoward effect on 
mucosa of the small intestine.^ 

i-McDermott, Textbook of Medicine, 15th Ed. 1979, W.B Saunders Co , 
elphia, pase 1959. 



TM 




In Cases with 
Chloride Deficiency... 

TWIN-K-CI 

Each 15 ml supplies 15 mEq of potassium ions and 4 mEq of chloride ions as a 
combination of potassium sluconate, potassium citrate, and ammonium chloride in a 
sorbitol and saccharin solution 

The good tasting potassium supplement with 
chloride 

• In hypokalemic hypochloremic alkalosis, 
chloride ions are required. Twin-K-CI is specially 
formulated to be a good tasting chloride 
containing potassium supplement. 

• Contains no potassium chloride. Twin-K-CI is a 
carefully balanced combination of organic 
potassium salts plus ammonium chloride. 

• In hypochloremic patients, potassium should 
be provided as the chloride salt, or chloride 
ion must be made available in some other 
form, such as ammonium chloride or sodium 
chloride.'' 

See prescribins information on last pase of this advertisement. 



CREME 



DESCRiPTION 

F-E-P Creme is a topical water soluble a ntJ- inflammatory anesthetic 

preparation intended for treatment of various inflammatory skin 

disorders Tfie dru3 contains the following active ingredients. 

lodochlorhydroxyquin 3 0% 

Pramoxine Hydrochloride 5% 

Hydrocortisone 10% 

INDICATIONS AND USAGE 



Based on a review of this drug by the National Academy of 
Sciences-National Research Council and/or other information, 
FDA has classified the indications as follows^ "Possibly" effec- 
tive: Contact or atopic dermatitis,- impetigimzed eczema; 
nummular eczema, infantile eczema, endogenous chronic 
infectious dermatitis, stasis dermatitis; pyoderma, nuchal 
eczema and chronic eczematoid otitis externa, acne urticata; 
localized or disseminated neurodermatitis; lichen simplex 
chronicus, anogenitdl pruritus (vulvae, scroti, am), folliculitis; 
bacterial dermatoses, mycotic dermatoses such as tinea 
(capitis, cruns corporis, pedis), moniliasis, intertrigo. Final 
classification of the less-than-effective indications requires 
further investigation. ^^^ 



Pramoxine Hydrochloride promptly relieves pain and itch This 
compound may be used safely on the skin of those patients 
sensitive to the "came" type local anesthetics. 
COKTRAINDIG^ONS 

Hypersensitivity to F-E-P Creme, or any of its ingredients or 
related compounds, lesions of the eye; tuberculosis of the skin, 
most viral skin lesions (including herpes simplex, vaccinia and 
varicella). 
WARNINGS 

This product is not for ophthalmic use 

In the presence of systemic infections, appropriate antibiotics 
should be used. 
USE IN PREGNANCY 

Topical steroids fiave not been reported to have an adverse 
effect on pregnancy However, fetal abnormalities have been 
produced in pregnant laboratory animals that have been exposed 
to large doses of topical corticosteroids. Drugs of this class 
should not be used extensively during pregnancy. 
PRECAUTIONS 

F-E-P Creme may be irritating to the skin in some patients If 
irritation occurs discontinue therapy Staining of clothes or hair may 
also occur with use of this preparation. Although systemic toxicity 
has not been reported with this drug, adrenal pituitary suppression 
IS possible, especially when the drug is used extensively or kept 
under an occlusive dressing for a prolonged period 
lodochlorhydroxyquin can be absorbed through the skin and 
interfere with thyroid function tests. Therapy with this preparation 
should stop at least a month before performance of these tests 
The ferric chlonde test for phenylketonuria (PKU) can be positive 
if F-E-P Creme is on the diaper or in the urine. 
Prolonsed use of this drug may result in an overgrowth of non- 
susceptible organisms requiring appropriate therapy 
ADVERSE REACTIONS 

Skin rash or hypersensitivity may occur following topical applica- 
tion 

The following local adverse reactions have been reported with 
topical corticosteroids, especially under occlusrve dressings 
burning, itching, in^rtation, dryness, folliculitis, hypertrichosis, acnei 
form enjptions, hypopigmentation, perioral dermatitis, allergic 
contact dermatitis, maceration of the skin, secondary infection, 
skin atrophy, stnae, miliaria Discontinue therapy if untoward 
reactions occur 

DOSAGE AND ADMINtSTRAHON 

Apply a thin layer of the drug to affected parts 3-4 times daily 
Note: 
1. F- E-P Creme is distributed with 3 0% lodochlorhydroxyquin 

for use when ant itiactena I/a nti fungal activity is desired, 
g- F-E-P Creme (Plain) is the regular formulation, but v^hout 

lOdoc hlorfiydroxyq u I n 
Both of these preparations contain pramoxine fiydrochlonde, 
w/hich has topical anesthetic properties. Pramoxine is not chem- 
ically related to benzoic acid or amide type topical anesthetics 
Patients can tolerate pramoxine although they may be sensitive to 
other "came" type of topical or local anesthetics. 
HOWSUPPUED 

F-E-P Creme Vi ounce (15 gm) tubes NDC 0524-0096-51 

F E-P Creme Plain J4 ounce ( IS gm) tubes NDC 0524-0025-51 
Federal law prohibits dispensing without a prescription 
July 1980 



SU-TON 



DESCRIPTION 

Forty-five milliliters of 5U-TON contain the following ingredients 

Pentylenetetrazol. 30 mg 

Niacin 50 mg 

Vitamm B-1 10 mg 

Vitamin B-2 5 mg 

Vitamin B-6 1 mg 

Vitamin B-12 3 meg 

Choline 100 mg 

Inositol 50 mg 

Manganese (as Manganese Sulfete) 1 mg 

Magnesium (as Magnesium Sulfate) 2 mg 

Zinc (as Zinc Sulfate) 1 mg 

Iron (as Feme Pyrophosphate, Soluble) 22 mg 

Alcohol 18% 

INDKAnONS AND USAGE 

SU-TON contains pentylenetetrazol which may be helpful in the 

older patient as an analeptic agent when mental confusion and 

memory defects are present SU-TON also contains vitamins, 

trace minerals, and iron, for those patients who may tvenefit by 

preventing the development of a deficiency. 

CONTRAINDKAnONS 

Epilepsy, convulsive disorders or known history of sensitivity to 

any of the listed active ingredients. 

WARNINGS 

The safety of this preparation during presnancy and lactation has 

not been established. Use of this dnjg requires tfiat the physician 

evaluate the potential benefits of the drug against arry possible 

fiazard to the mother and child 



PRECAUTIONS 

Although there are no absolute contraindications to pentyl- 
enetetrazol, it should t»c used with caution m epileptic patients 
or those knov^ to have a low convulsive threshold or a focal 
bram lesion Caution should be exercised when treating patients 
with high doses of SU-TON v^o have heart disease. Wiile 
pentylenetetrazol does not act directly on the myocardium, the 
results from central vagal stimulation could cause bradycardia. 
ADVERSE REACTIONS 

Pentylenetetrazol in high doses may produce toxic symptoms 
typical of central nervous system stimulants, wtiich act on the 
higher motor centers and the spinal cord. Convulsions resulting 
from this drug are spontaneous and are not induced by external 
stimuli They usually last for several minutes and arc followed by 
profound depression and respiratory paralysis. Death has been 
reported from the ingestion of 10 grams of pentylenetetrazol. 
DRUG ABUSE 

Drug dependence has not been reported with SU-TON 
OVERDOSAGE 

Signs and symptoms of acute overdose may be due principally 
from overstimulation of the central nervous system and from 
excessive vasodilatation with resulting autonomic nervous sys- 
tem imbalance The symptoms may include the following 
vomiting, agitation, tremors, hyperreflexia, sweating, confusion, 
hallucinations, headache, hyperpyrexia, tachycardia Treatment 
consists of appropriate suppoaive measures If signs and symp- 
toms are not too severe and the patient is conscious, gastric 
evacuation may be accomplished by induction of emesis or 
gastric lavage 

Intensive care must be provided to maintain adequate circulation 
and respiratory exchange 
DOSAGE AND ADMlNISTRAnON 

One tablespoonful (15 ml) 3 times a day 20-30 minutes before 
meals This drug is not for use m children under 12 years of age. 
HOW SUPPUED 

Bottles of 473 ml (16 fl oz) NDC 0524-0015-16 

Federal law prohibits dispensing without prescription. 
February 1980 



DESCRIPTION 

Each IS milliliter (one tablespoonful) supplies 20 mEq of 
potassium ions as a combination of potassium gluconate and 
potassium citrate in a sorbitol and saccharin solution. 
INDICAnONS AND USAGE 

For use as oral potassium therapy m the prevention or treatment 
of hypokalemia which may occur secondary to diuretic or 
corticosteroid administration It may be used in the treatment of 
cardiac arrhythmias due to digitalis intoxication 
CONTRAINDICAHONS 

Severe renal impairment with ohguna or azotemia, untreated 
Addison's disease, adynamia episodica hereditaria, acute dehy- 
dration, heat cramps and hyperkalemia from any cause. This 
product should not be used m patients receiving aldosterone 
antagonists or triamterene. 
WARNINGS 

T\)WN-K (potassium gluconate and potassium citrate) is a palatable 
form of oral potassium replacement. It appears that little if any 
Cjotassium gluconate-citrate penetrates as far as the jejunum or 
ileum where enteric coated potassium chloride lesions t^ve been 
noted Excessive, undiluted doses of TWIN-K may cause a saline 
laxative effect 

To minimize gastrointestinal irritation, it is recommended tfiat 
TWlN-K be taken with meals or diluted with water or fruit juice 
A tablespoonful (15 ml) m 8 ounces of water is approximately 
isotonic More than a single tablespoonful should not be taken 
without prior dilution. 
PRECAUTIONS 

Potassium is a major intracellular cation which plays a significant 
role in body phvsiology The serum level of potassium is normally 
3 8-50 mEq/liter While the serum or plasma level is a poor 
indicator of total body stores, a plasma or serum level below 
3.5 mEq/liter is considered to be indicative of hypokalemia. 
The most common cause of hypokalemia is excessive loss of 
potassium in the urine. However, hypokalemia can also occur with 
vomiting, gastric drainage and diarrhea 

Usually a potassium deficiency can be corrected by oral adminis- 
tration of potassium supplements. With normal kidney function, 
It IS difficult to produce potassium intoxication by oral 
administration. However, potassium supplements must be admin- 
istered with caution sirKe, usually the exact amount of the 
deficiency is not accurately known. Checks on the patient's 
clinical status and periodic EKG and/or se-ojm potassium levels 
should be made High serum potassium levels may cause death 
by cardiac depression, arrhythmias or arrest. 
In patients with hypokalemia who also have alkalosis and a 
chloride deficiency (hypokalemic hypochloremic alkalosis), there 
will be a requirement for chloride ions TWIN-K is not recom- 
mended for use in these patients 
ADVERSE REACnONS 

Symptoms of potassium intoxication include paresthesias of the 
ex^emltics, flaccid paralysis, listlessness, mental confusion, weak- 
ness and heaviness of the legs, fall in blood pressure, cardiac 
anrhythmias and heart block. Hyperkalemia may exhibit the follow- 
ing electrocardiographic abnormalities, disappearance of the 
P wave, widening and slurring of the QRS complex, changes of the 
ST segment and tall peaked T waves. 

TWIN-K taken on an empty stomach in undiluted doses larger than 
30 ml can produce gastric irritation with r^ausea, vomiting, diarrhea, 
and abdominal discomfort. 
OVERDOSAGE 

The administration of oral potassium supplements to persons 
with normal kidney function rarely causes serious hyperkalemia. 
However, if the renal excretory function is impaired, potentially 
fatal hyperkalemia can result It is important to note that hyper- 
kalemia IS usually asymptomatic and may be manifested onfy by 
an increased serum potassium concentration with or without 
EKG changes. Treatment measures include 

1 Elimmation of potassium containing drugs or foods. 

2. Intravenous administration of 3(X) to 500 ml/hr of a 10% 
dextrose solution containing 10-20 units of crystalline insulin 
per 1000 milliliters. 

3. Correction of acidosis 

4 Use of exchange resins or peritoneal dialysis. 



I 

ents^n 
^serurnipH 



( 



In treating hyperkalemia, it should be noted that patientS' 

on digitalis can develop digitalis toxicity when the 

sium concentration is changed too rapidly 

DOSAGE AND ADMINISTRATION 

The usual adult dosage is one tablespoonful (15 ml) in6fitt 

ounces of water or fruit juice, two to four times a day.TNB< 

supply 40 to 80 mEq of potassium ions. The usual prevcrtti 

dose of potassium is 20 mEq per day while therapeutic (to 

range from 30 mEq to 100 mEq per day Because of the polQ 

for gastrointestinal irritation, undiluted large single doses (30ffl 

more) of TWtN-K are to be avoided 

Deviations from this schedule may be indicated, since no „ 

total daily dose can be defined, but must be governed t^dl 

obsen/ation for clinical effects. 

HOW SUPPUED 

Bottles of 1 pint ( 16 fl oz ) NDC 0524008 

CAUTION 

Federal law prohibits dispensing without prescription 

July 1980 



TWIN-K-CI 



TM 



DESCRIPTION 

Each 15 ml (one tablespoonful) supplies 15 mEq of 
ions and 4 mEq of chloride ions as a combination of 
gluconate, potassium citrate, and ammonium chloride, 
and saccharin solution. 
INDICAnONS 

For use as oral potassium therapy in the prevention or treeb 
of hypokalemia which may occur secondary to diutft 
corticosteroid administration. It may be used in the treatmo 
cardiac arrhythmias due to digitalis intoxication. 
Potassium and chloride are usually the salts of choice in thei 
ment of hypokalemia since chloride and potassium deficien 
are likely to be associated with each other 
CONTRAINDICAnONS 

Severe renal impairment with oliguria or azotemia, untrs 
Addison's disease, adynamia episodica hereditaria, acute d 
dration, heat cramps and hyperkalemia from any cause 
product should not be used in patients receiving aldose 
antagonists or triamterene. 
WARNINGS 

TWlN-K-CI IS a palatable form of oral potassium repi 
Excessive, undiluted doses of TWIN-K-CI may cause a S 
laxative effect 

To minimize gastrointestinal irritation, it is recommended 
TWlN-K-Cl be taken v^th meals or diluted with water or friAj 
A tablespoonful (15 ml) in 8 ounces of water is approwm 
isotonic More tfian a single tablespoonful should not betn 
without prior dilution 
PRECAUTIONS 

Potassium is a major intracellular cation which plays a sign( 
role in body physiology The serum level of potassium is nor 
3.8-5.0 mEq/liter While the serum or plasma level is a 
indicator of total body stores, a plasma or serum level b 
3.5 mEq/liter is considered to be indicative of hypokaleme 
The most common cause of hypokalemia is excessive lo i 
potassium in the urine Hovs/ever, hypokalemia can also occu I [^i 
vomiting, gastric drainage and diarrhea 
Usually a potassium deficiency can be corrected byoraladi 
tration of potassium supplements With normal kidney functio 
difficult to produce potassium intoxication b^ oral adrnineO 
However, pxDtassium supplements must be administered 
caution since, usually the exact amount of the deficieicy 
accurately known Checks on the patient's clinical statu 
periodic EKG and/or serum potassium levels should be n 
High serum potassium levels may cause death by cardiac di 
sion, an-hythmias or arrest 

In patients with hypokalemia vA\o also have alkalosis i 
chloride deficiency (fiypokalemic hypochloremic alkalosis), 
will be a requirement for chloride ions TWIN-K-CI is ti 
mended for use m these patients. 
ADVERSE REACTIONS 

Symptoms of potassium intoxication include paresthesias 
extremities, flaccid paralysis, listlessr>ess, mental confusion, 
ness and heaviness of the legs, fall in blood pressure, o 
antiythmias and heart block. Hyperkalemia may exhibit thcfi 
ing electrocardiograpic abnormalities, disappearance of 
wave, widening and slurring of the QRS complex, changes 
ST segment and tall peaked T waves. 
TWiN-K-CI taken on an empty stomach in undiluted doscs 
than 30 ml can produce gastric m^itation with nausea, va 
diarrhea and abdominal discomfort. 
OVERDOSAGE 
The administration of oral potassium supplements to persor 
normal kidney function rarefy causes senous hyperkalemia 
ever, if tfie renal excretory function is impaired, potential 
hyperkalemia can result. It is important to note that hypert 
is usually asymptomatic and may be manifested only 
increased serum potassium concentration with or wrtha 
changes- 
Treatment measures include 

1 . Elimination of potassium containing drugs or foods. 

2. Intravenous administration of 300 to 500 ml/hr of 
dextrose solution containing 10-20 units of crystalline 
per 1000 milliliters 

3 Correction of acidosis. 

4. Use of exchange resins or peritor>eal dialysis 
In treating hyperkalemia, it should be noted that patients sts 
on digitalis can develop digitalis toxicity v^rfien the serum 
sium concentration is changed too rapidly. 
DOSAGE AND ADAUNISTRAFION 
The usual adult dosage is one tablespoonful (15 ml) 
fluid ounces of water or fruit juice, two to four times 
This will supply 30 to 60 mEq of potassium ions and 8 to 
of chloride ions. The usual preventative dose of potas 
20 mEq per day vs/hile therapeutic doses range from i 
to 100 mEq per day Because of the potential for gastro^i 
irritation, undiluted large single doses (30 ml or m(« 
TWIN-K-CI are to be avoided. ^ 

Deviations from this schedule maybe indicated, since no. | 
total daily dose can be defined, but must be gcwerneob 
obser/ation for clinical effects. 
HOW SUPPUED Bottles of 1 pint (16 fl oz) 

NDC 0524^ 



MANUFAQURED & DISTRIBUTED BY 

Boots Pharmaceuticals, Inc* 

Shreveport, Louisiana 71106 

Pioneers in Medicine For the Family 



k 




JOHN S. RHODES, M.D. 

Our masthead no longer shows the name of John 
Rhodes as associate editor. With a real sense of loss, 
we have acquiesced in his desire to leave the Journal. 
When I became editor, his kindness, knowledge of the 
state and of our society and ability to provide the quiet 
support that helps one accommodate to a new world 
quickly were invaluable and have continued to be so. 
He shares many of those enviable traits of the founder 
of this Journal. Wingate Johnson, not the least the 
ability to recognize that what is right for patients is 
right for medicine and to act accordingly. 

His successor. Jack Hughes, is also a urologist with 
similar attributes: experience in the society, an ap- 
preciation of the complexities of modern medicine and 
a broad understanding of the trends and events which 
determine what North Carolina is and will be. Isak 
Dinesen, the Danish author, has suggested that the 
body may be well considered as an elegant means of 
converting wine into water. Urologists and nephrolo- 
gists have assumed the medical responsibility for 
maintaining the integrity of this system. The two of us, 
nephrologist and urologist, under your direction 
through the editorial board, will strive in the editorial 
arena to keep the Journal healthy and to ensure ap- 
propriate verbal output in our pages. 

J.H.F. 

MEDICINE IN THE WORKPLACE 

The Food and Drug Administration (FDA) has re- 
cently decreed that descriptive leaflets must be pro- 
vided patients when they have prescriptions filled for 
10 drugs including the three most commonly used 
psychoactive agents. The action was almost certainly 
prompted, at least in part, by concern that too many 
people are taking too much psychoactive drug too 
casually. Proctor's report in this issue of the Journal 
suggests, however, that things in some workplaces 
may not be as bad as they seem. But good news 
competes poorly with gloom and doom dispensed by 
newspapers, magazines and television stations. 

Proctor's study of course is limited but its very 
limitations should provoke questions and stimulate 
investigators. No comparative data are provided 
about quantities of drug consumed nor are the hazards 
of employment in the furniture industry described. 
What is the pattern of drug use in the textile and 
tobacco industries? Are there regional differences in 
prescription drug consumption? What proprietary 

August 1981, NCMJ 



preparations were being used simultaneously by his 
respondents? How compliant were respondents in 
following their physicians' instructions? How fre- 
quently were the users of diazepam being seen by their 
doctors? Why were psychoactive agents prescribed 
for them in the first place? 

Before becoming overly optimistic about the benig- 
nity and beneficence of diazepam, we should consider 
the plight of phenacetin which has recently been van- 
quished from the marketplace by the FDA. For some 
years Swiss, Scandinavian and Australian observers 
have been warning us that analgesic compounds when 
abused can lead to serious renal disease. Analgesic 
abuse is more common in the South and particularly in 
the North Carolina textile belt where such practice has 
important implications for dialysis and transplant pro- 
grams.' Gonwa and his colleagues in Winston-Salem 
have recently reported the largest series in this coun- 
try of patients with transitional cell carcinoma of the 
urinary tract attributable to analgesic abuse, em- 
phasizing the latency of phenacetin and its metabolites 
as carcinogenic compounds.- So prolonged observa- 
tion of the effects of psychoactive drugs in the work- 
place is essential. 

J.H.F. 



Gonwa TA. Hamilton RW. Buckalew Jr. VM: Chronic renal failure and endstage renal 
disease in northwest North Carolina: importance of analgesic-associated nephropathy. 
Arch Intern Med 141: 462-465, 1981. 
. Gonwa TA. Corbett WT. Schey HM. Buckalew VM: Analgesic associated ne- 
phropathy and transitional cell carcinoma of the urinary tract. Ann Intern Med 
93:249-252, 1980. 



THE PRICE OF CIVILIZATION OR 
YOUR pH HANGS IN THE BALANCE 

Our Western way of life has its advocates. We have 
after all vanquished smallpox and nearly annihilated 
many other plagues of the past and can claim as 
triumph the lengthening of life and the decreasing of 
infant mortality. But our critics point out that we have 
contaminated the earth, that as our ancestors we suf- 
fer sickness because of the sin of conspicious con- 
sumption — of salt, coffee, fat, cigarettes, gasoline, 
coal. As the conservative says, yesterday will be 
wonderful, so the liberal responds, tomorrow was 
grand. 

But what of the now where we pay our taxes and 
listen for the sounds of falling hair and hardening 
arteries? Accept it, deny it, ignore it or simply keep 
going? When we are uncertain we can contemplate our 
image in the mirror in the hope that this will lead us to 



567 



deliverance but before doing so we must recall what a 
seer said about Narcissus, the Thespian: "Narcissus 
will live to a ripe old age, provided that he never 
knows himself." But he fell in love with his own 
reflection in a spring and tried to possess himself. 
Failing, he stabbed himself and where his blood fell to 
earth the Narcissus grew and bloomed. 

Self-love can be appealed to and controlled; it need 
not lead to suicide. In fact serving such needs is big 
business which may even incorporate a drop or two of 
elixir of science in its cosmetic distillations. Take the 
male face, so vulnerable to razor nicks, so necessary 
to be saved in critical personal encounters. What can 
one do about one's face and avoid being called narcis- 
sistic? According to a buyer for Bloomingdale's in 
New York, men are showing signs of sophistication 



"from the neck up." Today we are using moisturizers, 
restoring our facial pH balance, bronzing our skin 
without sun and applying RN A biocomplex creams as 
well as a whole host of other mysterious revivifying 
unguents. The pH balancer is the liquid gel Aramis 
which presumably deciphers the Henderson- 
Hesselbach equation between forehead and chin, ne- 
gates wrinkles, reverses the alkaline tide of tears shed 
for lost youth and helps us pass the acid test. 

Remember Dumas's rollicking adventure. The 
Three Musketeers. Porthos, Athos and Aramis. That 
Aramis retreated so from his worldly self that he en- 
tered a monastery. Today's Aramis subtly insinuates a 
different vision — that a man who uses the right 
cosmetics is his own best friend. 

J.H.F. 



MEDICAL PLACE AT 



5ffi 



TrCEISTTHl 




Here is an opportunity for you in one of 
the more progressive regional medical 
communities "Fayetteville, North Caro- 
lina". 

Adjacent to the Cape Fear Valley Hospi- 
tal, Vyquest Development Corp. is de- 
veloping an outstanding condominium 
building satisfying the needs of the 
growth oriented medical professional. 
Not only do we have a handsome, effi- 
cient building, but we have it in the 
superbly planned Cape Center Office 
Park in the region's most desirable and 
sought after location. 

For our brochure, call 919-484-6530 or 
send your card to: 

Vyquest Development Corp. 

3300 Cape Center 

Fayetteville, North Carolina 28304 



568 



Vol. 42, No. 8 





"Batients a Tain 



By Karen Zupko 

Director, AMA 

Department of Practice Management 

Has this scene occurred lately in your office? 

"Mr. Patient, that will be $25.00 for today's visit," 
says your medical assistant. 

Angry and red-faced Mr. Patient replies, "Well 
I've always paid my bill here. Why don't you just 
send me a statement like you always do? 

"Because, sir, this is our new policy," your as- 
sistant curtly replies. 

Meanwhile, all the patients in the reception room 
have put down Newsweek, Ladies Home Journal, 
and last year's copy of Ski magazine. They are 
sittingattheendof their chairs, eagerly listening to 
see how Mr. Patient is going to get out of this and 
wondering how they'll handle the situation when 
they're confronted with their bill for your services. 

Embarrassed, Mr. Patient, tells the assistant he 
doesn't have his checkbook and he leaves with her 
calling out "But don't forget next time!" 

Well.thetruth istheremay not beanexttime. Mr. 
Patient may decide to go elsewhere for his medical 
care. 

But this doesn't have to be the case. If your off ice 
is one of the many all across the country now ask- 
ing patients to payfortheirofficevisitson the same 
day you can implement the policy successfully and 
still keep your patients happy by following a few 
9asy procedures. 

First, we recommend that you send all of your 
3Stablished patients a letter explaining the new 
Dolicy. It will help reduce long telephone ex- 
3lanations for your assistants and eliminate the 
surprise factor that so many patients resent. Send 
he letter on your stationery about two to three 
nonths before implementing the policy. It might 
ay something like this. 

Dear Patient, 
Inflation is a growing problem for everyone, in- 
luding medical offices. Today we find ourselves 

August 1981. NCMJ 



confronted with ever-increasing costs for almost 
every supply and service we use in rendering pro- 
fessional care to you. 

Rather than raise our fees now, which we may 
have to do from time to time, we are asking your 
help in a new cost-cutting plan. Beginning on (give 
a date two to three months in advance) we will ask 
you to pay for your office call at the time of your 
visit. By asking you to do this we can significantly 
reduce the costs of billing and bookkeeping. 

We understand that occasions may arise when it 
will be necessary for you to ask for a statement 
rather than paying at the time of service. We also 
recognize, as we always have that patients who 
require extensive treatment may need payment 
plans. 

We wanted to explain this new system to you well 
in advance because your understanding and 
cooperation are so Important. Please remember 
that if you have questions about this or any other 
office policy or procedure we will be pleased to 
discuss them with you. We value you, our patient, 
and will continue to provide you with our best pro- 
fessional care. 

Sincerely, 
XYZ Medical Office 

But your patient relations effort shouldn't stop 
here. Next, you and your front office personnel 
need to discuss how firm you plan to be and this 
varies from office to office. In any case, your medi- 
cal assistants need to know what you're thinking is 
on this topic and be assured that you're going to 
back them up. (No fair for the doctor to tell patients 
"not to worry about the bill" if they ask about your 
fees in the examining room unless you mean just 
that!) 

Your medical assistants should also make a 
point of reminding patients of the new policy when 
they call to make an appointment. For example 
they can say, "Mrs. Black, we have you scheduled 
for next Tuesday at 2:00 p.m. Your office visit will 
be $10.00 and any lab work the doctor orders will 

569 



be extra." If Mrs. Black objects, your assistant can 
remind her about the letter and that this request is 
being made of all patients. If Mrs. Black says she 
won't be able to pay, your assistant should proba- 
bly go ahead and keep the appointment for her and 
tell her she's making a note of the agreement to 
send a statement on Mrs. Black's ledger card. 
Later, you or your bookkeeper may want to have a 
private conversation with Mrs. Black if she persists 
in being an exception to the rule. 

Office layout and design also play a part in mak- 
ing this policy work successfully. It's going to be 
much easier, if you have a separate check out 
counter, away from the reception room or an area 
that gives your assistant and the patient some de- 
gree of privacy. It will allow the patient to give an 
honest explanation of their circumstance and your 
assistant the ability to make some arrangement to 
suit that patient's needs without curious eyes and 
ears, looking and listening. If you need to build a 
wall or install a door, do so. It's going to be worth 
the investment. 

How should your assistant ask for payment? 
That depends on you. Offices taking the more 
flexible approach, simply have the assistant say, 
"Mr. Patient, your visit today is $15.00 or, "Mr. 
Patient, your visit is $15.00 and we invite payment 



570 



today." The office that is willing to take a more 
aggressive approach has the assistant say, "Mr. 
Patient, yourvisittoday is$15.00." "Would you like 
to pay by cash or check?" Both are better tech- 
niques than simply saying. 'Your visit today is 
$1 5.00, would you like to pay ? " No one would like 
to pay today — anywhere, anytime, including your 
office! This simply invites, the "send me a bill" 
response. 

Now, what happens if the patient says, "Gee, you 
know I always try to come prepared, but today, I 
forgot my checkbook. " That's going to happen 
sometimes, and your assistant should be prepared. 
She should say, "Miss Patient, that's okay, we un- 
derstand, here's your statement and an envelope 
please mail your payment, just as soon as you can." 
Most offices report that they receive payment in a 
few days, without ever having to send a bill. You 
might make that return envelope a color so it's easy 
to spot when the payment comes in. 

The important thing to keep in mind about ask- 
ing for payment at the time of service is good pa- 
tient relations and that you're going to have to 
make exceptions. With these two thoughts in mind, 
you're sure to succeed, without giving your pa- 
tients a new pain. 






Vol. 42. No. 



Is 
Is 



ill 



NC-AMA ^^ 
Delegates' Report f-^J 



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North Carolina came home the victor with the election of one 
)F its Delegates, James E. Davis, M.D., of Durham, to the position 
)F Vice-Speaker of the AMA House of Delegates, at the June 7-11 
1EETING IN Chicago. 

It was a busy session. With so much business, this report 
)bvisouly can only touch briefly on a few major items- 
ORGANIZATION AND DUES INCREASE 



A MAJOR Board of Trustees' report calling for reorganization 
)F AMA structure and staff and a $35 annual dues increase received 

lOST ATTENTION. We APPROVED MOST BOARD PROPOSALS. ThE 1982 DUES 
HLL BE $285 FOR REGUALR MEMBERS. MeDICAL StUDENT AND RESIDENT 
)UES REMAIN AT $15 AND $35 RESPECTIVELY, 

In ADOPTING A NEW FUNCTIONAL PROFILE FOR THE AMA, THE HoUSE 
:ALLED for REPRESENTATION OF THE MEDICAL PROFESSION TO BE THE 
DUMBER ONE PRIORITY FOR THE ASSOCIATION. OtHER PRIMARY FUNCTIONS ARE: 

--Providing information, both scientific and socio-economic 
--Establishing and maintaining standards of conduct and 

performance 
--Sharing with other organizations the maintenance and 

implementation of educational standards. 

In RECOGNITION OF THE SPECIAL FINANCIAL CIRCUMSTANCES OF NEW 
HYSICIANS AND THOSE IN MILITARY SERVICE, THE HoUSE ADOPTED SOME 
)UES INCENTIVES. We NEED TO ENCOURAGE PHYSICIANS TO JOIN AND 
lECOME INVOLVED IN ORGANIZED MEDICINE EARLY IN THEIR MEDICAL CAREER. 
^OUNG PHYSICIANS IN THE FIRST YEAR OF PRACTICE NOW PAY 50% OF THE 
tEGULAR DUES; AND AT THE RECENT MEETING, THE HoUSE VOTED TO SET 
"HE DUES OF PHYSICIANS IN THEIR SECOND YEAR OF PRACTICE AT 75% 



OF REGULAR DUES, BEGINNING IN 1982, PHYSICIANS IN MILITARY SERVICE 
WILL PAY TWO-THIRDS OF REGULAR DUES, 

DIRECT MEMBERSHIP 



I 



In A MAJOR DECISION WITH FAR-REACHING IMPLICATIONS FOR THE 
STRENGTH AND VITALITY OF THE AMA, WE CHANGED THE ByLAWS TO ESTABLISH 
A DIRECT AMA MEMBERSHIP OPTION, ThE AMA WILL PUT ITS FIRST EMPHASIS 

on recruiting members in cooperation with state medical societies 
that join with the ama in a coordinated marketing campaign, 

We learned that although AMA membership has increased in abso- 
lute NUMBERS, THERE ARE STILL 241,000 PHYSICIANS WHO DO NOT BELONG, 

Of these, 178,000 also do not belong to state or county medical 
societies, 

In ADDITION TO THIS DIRECT MEMBERSHIP OPTION, WE CHANGED THE 

Bylaws so that direct members will be counted toward determining 
the number of delegates from each state society, 

The AMA will bill all non-member physicians and medical student 
AFTER the April 30 delinquency date each year. Lists of those physi- 
cians who apply for AMA direct membership will be sent to state 
medical associations for review before processing is completed, All 
objections to applicants for direct membership will be referred to 
the Judicial Council for prompt disposition, Accepted physicians 

AND students WILL BE URGED TO JOIN STATE AND COUNTY SOCIETIES, 

A FULL REVIEW AND REAPPRAISAL OF THE DIRECT MEMBERSHIP PROGRAM 
AFTER THREE YEARS WAS DIRECTED BY THE HoUSE , 

COMPETITION LEGISLATION 

The House adopted a comprehensive report of the Board of 
Trustees pertaining to "pro-competition" National Health Insurance 
proposals now under consideration by the Congress, The Board with 
concurrence from the Council on Legislation and the Council on 
Medical Service expressed some serious concerns with these bills 
and how these proposals would affect the way medicine will be 
practice in the future. 



The competition proposals would result in a shift in the way 
medical services are delivered, currently, medical care is delivered 

through a DECENTRALIZED MARKET. ThESE PROPOSALS ASSUME THAT GIVEN A 
COST INCENTIVE/ PATIENTS WILL ACCEPT RESPONSIBILITY FOR FIRST DOLLAR 
HEALTH CARE COSTS AND CHOOSE A HEALTH INSURANCE PLAN WITH FEWER 
BENEFITS. Thus, IT IS ASSUMED THE PATIENT WILL BE MOTIVATED TO USE 
FEWER HEALTH CARE SERVICES. 

The APIA BELIEVES that the likely result will be market CONCEN- 
TRATION, The REPORT SAID "sponsors of INSURANCE PLANS, PARTICULARLY 
UNDER THE MORE COMPREHENSIVE COMPETITION MODELS, WOULD BE EXPECTED 
TO EXERCISE THEIR PURCHASING POWER TO CONTROL SELECTION OF PROVIDERS 
AND FACILITIES THROUGH SPECIAL ARRANGEMENTS WITH THEM". 

The House concurred with the Board's conclusion that the advo- 
cates OF competition assume that patients are preoccuppied with 
price and that this assumption is yet to be fully demonstrated, 
Accessibility, reliability, and quality are just as important--and 
maybe more so--than price. 

In other actions, the House voted to: 

--Support the elimination of government funds for new start-ups 

OF health maintenance organizations and for the termination 

OF funds for other HMO's after completion of the current 

funding cycle. 
--Endorse the concept of equal rights for men and women, but 

NOT THE Equal Rights Amendment, 
--Recommend to hospital staffs that admission histories and 

physicals be performed only by physicians. 
--Urge the Food and Drug Administration to accelerate review 

of drugs on its "lacking evidence of effectiveness list". 
--Urge the Federal Aviation Agency to study medical emergencies 

ON commercial planes and how currently treated with the 

required medical kits, 
--Support a bill placing a moratorium on Federal Trade 

Commission activities involving professionals. 
--Oppose state laws making a physician's licensure contingent 

upon providing services to Medicaid beneficiaries or any 

other specified category of patients. 



--Have the AFIA develop an educational program dealing with 
child molestation, incest, and exploitation of children, 

With 283 Delegates, this was the largest House in AMA's history, 
Five state societies received an additional delegate seat due t-o 
membership increases. 

The House postponed granting delegate seats to several addi- 
tional specialty societies, The Board was asked to review the 
issue and report back. The Reference Committee noted that there were 

MANY objections TO GRANTING REPRESENTATION IN THE HOUSE TO ORGANI- 
ZATIONS OF SUB-SPECIALTIES WITH OVERLAPPING MEMBERSHIPS. ThERE ARE 
CURRENTLY 56 NATIONAL SPECIALTY SOCIETIES WITH REPRESENTATION IN 

THE House, 

Refer to the June 19/26 issue of American FIedical News for 

MORE detailed CONVENTION COVERAGE, 

APIA House meetings provide a unique educational opportunity, 

AND WE ENCOURAGE YOU TO ATTEND AND PARTICIPATE, AnY MEMBER OF THE 

Association may present testimony at the Reference Committee hear- 
ings AND, OF COURSE, CORRIDOR DISCUSSIONS ON THE ISSUES PROVIDE 
AMPLE OPPORTUNITIES TO GET YOUR VIEWS ACROSS, 

If YOU can't attend the meeting you CAN STILL BE REPRESENTED 
THROUGH YOUR DELEGATE, PlEASE LET YOUR DELEGATION KNOW YOUR OPINIONS, 

You can also prepare a resolution and request that it be submitted 
TO THE House. 

Many, many AMA policies began with an individual physician 
who had a good idea and developed it through the Democratic process. 



DELEGATES 
David G. Welton, M,D., Chairman 
John Glasson, M.D. James E. Davis, M.D. 

Frank R. Reynolds, M.D. Louis deS. Shaffner, M.D. 







For th^Qyi^osteoarthritis 
the proven power of 

Motrin 

ibuprofen, Upjohn 

600 mg Tablets 

One tablet ti.d. 

Please see the following page for a brief summary of prescribing information. 

I^john ^ 



The Upjohn Company • Kolamazoo. Michigan 49001 USA 



Motrin' Tablets (ibuprofen, Upjolin) 

Contraindications: Individuals hypersensitive to it, or wltti the syndrome of nasal 
polyps, angioedema, and bronchospastic reactivity to aspirin, iodides, or other non- 
steroidal anti-inflammatory agents. Anaphylactoid reactions have occurred in such 
patients. 

Warnings: Peptic ulceration and gastrointestinal bleeding, sometimes severe, have 
been reported Ulceration, perforation, and bleeding may end fatally. An association has 
not been established. Motrin should be given under close supervision to patients vmth a 
history of upper gastrointestinal tract disease, only after consulting ADVERSE REAC- 
TIONS 

In patients with active peptic ulcer and active rheumatoid arthritis, nonulcerogenic 
drugs, such as gold, should be tried If Motrin must be given, the patient should be under 
close supervision for signs of ulcer perforation or gastrointestinal bleeding. 

Chronic studies in rats and monkeys have shovirn mild renal toxicity characterized by 
papillary edema and necrosis Renal papillary necrosis has rarely been shov»n in 
humans treated with Motrin 

Precautions: Blurred anil/or diminished vision, scotomata, and/or changes in color 
vision have been reported. If these develop, discontinue Motrin and the patient should 
have an ophthalmologic examination, including central visual fields and color vision 
testing. Fluid retention and edema have been associated vtWU Motrin: use with caution in 
patients with a history of cardiac decompensation or hypertension Motrin is excreted 
mainly by the kidneys In patients with renal impairment, reduced dosage may be nec- 
essary. Prospective studies of Motrin safety in patients with chronic renal failure have 
not been done Motrin can inhibit platelet aggregation and prolong bleeding time. Use 
with caution in persons with intrinsic coagulation defects and those on anticoagulant 
therapy. Patients should report signs or symptoms of gaslroinleslinal ulceration or 
bleeding, blurred vision or other eye symptoms, skin rash, weight gam, or edema. To 
avoid exacerbation of disease or adrenal insufficiency, patients on prolonged cortico- 
steroid therapy should have therapy tapered slowly when Motrin is added. The anti- 
pyretic, anti-inflammalory activity of Motrin may mask inflammation and lever. 
Drug Inleraclions. Aspirin: used concomitantly may decrease Motrin blood levels 
Coumarin: bleeding has been reported in patients taking Motrin and coumarin. 
Pregnancy and nursing mothers: Motrin should not be taken during pregnancy nor by 
nursing mothers 
Adverse Reactions 

The most freguent type of adverse reaction occurring with Motrin is gastrointestinal, of 
which one or more occurred in 4°o to 16% of the patients 

Incidence Greater Than 1% (but less than 3%) -Probable Causal Relationship 
Gaslroinleslinal: l^ausea;' epigastric pain; heartburn:' diarrhea, abdominal distress, 
nausea and vomiting, indigestion, constipation, abdominal cramps or pain, fullness of Gl 
tract (bloating and flatulence); Central Nervous System: Dizziness: headache, nervous- 
ness; Dermatologic: Rash (including maculopapular type), pruritus: Special Senses: Tin- 
nitus: Metabolic/Endocrine: Decreased appetite. Cardiovascular: Edema, fluid retention 
(generally responds promptly to drug discontinuation: see PRECAUTIONS). 
Incidence Less Than 1%-Probable Causal Relationship" 

Gaslroinleslinal: Gastric or duodenal ulcer with bleeding and/or perforation, gastroin- 
testinal hemorrhage, melena. gastritis, hepatitis, jaundice, abnormal liver function tests: 
Central Nervous System: Depression, insomnia, confusion, emotional lability, somnolence, 
aseptic meningitis with fever and coma: Dermatologic: Vesiculobullous eruptions, urti- 
caria, erythema multiforme, Stevens-Johnson syndrome, alopecia. Special Senses: 
Hearing loss, amblyopia (blurred and/or diminished vision, scotomata, and/or changes 
in color vision) (see PRECAUTIONS): Hematologic: Neutropenia, agranulocytosis, aplastic 
anemia, hemolytic anemia (sometimes Coombs' positive), thrombocytopenia with or 
without purpura, eosinophilia, decreases in hemoglobin and hematocrit: Cardiovascular: 
Congestive heart failure in patients with marginal cardiac function, elevated blood 
pressure, palpitations: Allergic: Syndrome of abdominal pain, fever, chills, nausea and 
vomiting, anaphylaxis, bronchospasm (see CONTRAINDICATIONS): Renal: Acute renal 
failure in patients with preexisting, significantly impaired renal function, decreased 
creatinine clearance, polyuria, azotemia, cystitis, hematuria: Miscellaneous; Dry eyes 
and mouth, gingival ulcer, rhinitis 
Incidence Less Than 1%-Causal Relationship Unknown" 
Gastrointestinal: Pancreatitis, Central Nervous System: Paresthesias, hallucinations, 
dream abnormalities, pseudotumor cerebri, Dermatologic: Toxic epidermal necrolysis, 
photoallergic skin reactions: Special Senses: Conjunctivitis, diplopia, optic neuritis: 
Hematologic: Bleeding episodes (eg , epistaxis, monorrhagia): Metabolic/Endocrine: Gyne- 
comastia, hypoglycemic reaction; Cardiovascular: Arrhythmia (sinus tachycardia, sinus 
bradycardia). Allergic: Serum sickness, lupus erythematosus syndrome, Henoch- 
Schdnlein vasculitis: Renal: Renal papillary necrosis 

'•'Reactions occurring in 3% to 9% of patients treated with Motrin (Those reactions 
occurring in less than 3°o of the patients are unmarked.) 

"'Reactions are classified under "Protiable Causal Relationship" (PCR) if there has been 
one positive rechallenge or if three or more cases occur which might be causally related. 
Reactions are classified under "Causal Relationship Unknown" it seven or more events 
have been reported but the criteria for PCR have not been met 
Overdosage: In cases of acute overdosage, the stomach should be emptied. The drug 
IS acidic and excreted in the urine, so alkaline diuresis may be beneficial 
Dosage and Administration: Do not exceed 2400 mg per day If gastrointestinal 
complaints occur, administer with meals or milk 

Rheumatoid arthritis and osteoarthritis, including flares of chronic disease: Sug- 
gested dosage is 300, 400, or 600 mg t Id org id. Mild to moderate pain: 400 mg every 
4 to 6 hours as necessary for relief of pain. 
Caution: Federal law prohibits dispensing without prescription. 

MEDB-5-S 



Upjohn 







nn A Public Service of This Magazine 
iSuia & The Advertising Council 



I 



THE UPJOHN COIvlPANY 
Kalamazoo, Michigan 49001 USA 



July1981 






Bulletin Board 



NEW MEMBERS 
of the State Society 



BLADEN 

Shieh. Richard Chen Hai. (R) P.O. Box 398. Hospital Drive. 
EHzabethtown 28337 

CUMBERLAND 

Osman, Magdy. (RESIDENT) 6309 Bell Terre Court. Fayetteville 
28304 

DURHAM-ORANGE 

Alva, Juan, (IM) 600 Yorktown Drive, Chapel Hill 27514 

Brady, Jr., Joseph Lawrence, (STUDENT) 425-A Cameron Av- 
enue, Chapel Hill 27514 

Bukowski. Elaine Marie. (AN) 600 Brookview Drive. Chapel Hill 
27514 

Friedman, Allan Howard, (NS) Box 3807, Duke Medical Center, 
Durham 27710 
^Houpt, Jeffrey Lyle, (P) 4533 Hunter's Ridge Trail, Durham 27707 

Levy. Stanley Benjamin, (D) 861 Willow Drive, Chapel Hill 27514 

Michener, James Lloyd. (RESIDENT) 407 Crutchfield Street, 
Durham 277(M 

Morse. Martin Albert, (STUDENT) 210 Alexander Ave., Apt. H, 
Durham 27705 

Nile. Peggy Leigh. (STUDENT) Box 2840. Duke Medical Center, 
Durham 27710 

Stankus, Paul Victor. (AN) 151 Dixie Drive. Chapel Hill 27514 

Stevens. Scott David. (STUDENT) Box 2794. Duke Medical Cen- 
ter. Durham 27710 

Turpin. James Wesley. (OM) 107 Longwood Drive, Chapel Hill 
27514 

Wechsler. Andrew Stephen, (TS) Box 3174, Duke Medical Center, 
Durham 27710 

FORSYTH-STOKES-DAVIE 

Adkins, Thomas Green, (RESIDENT) 408 Lawndale Drive, Win- 
ston-Salem 27104 

GUILFORD 

Badawi, Raouf Fahmy, (P) 212-A W. Wendover Avenue, Greens- 
boro 27401 

Holdemess, Jr., Howard, (PS) 200 E. Northwood St.. Ste. 400. 
Greensboro 27401 

MADISON 

Carr. Douglas Willits. (GP) Route #3. Box 57. Mars Hill 28754 

MECKLENBURG 

Black. Edward Barnwell. (R) 3665 Pelham Lane. Charlotte 28211 
Short. Jr.. Eari Degrey, (P) 3224 Chancer Drive, Chariotte 28210 

VEW HANOVER-BRUNSWICK-PENDER 

Rallis, Michael George, (IM) 301 S. McNeil Street. P.O. Box 1179, 
Burgaw 28425 

PITT 

Anderson, Charles Lynn, (RESIDENT) 121 N. Woodlawn, Green- 
ville 27834 

McGilliarddy, Denis Michael, (ORS) 307 Windsor Street, Green- 
ville 27834 



SURRY-YADKIN 

Beeson, Broadus Monroe, (FP) East Bend Community Health Ctr.. 

Box 126, East Bend 27018 
Bryant, James Edwin, (IM) Route #2, Box 211 F24, Yadkinville 

27055 

WAKE 

Dascomb, Harry Emerson, (IM) 11504 Bainbridge Terrace, 

Coachman's Trail. Raleigh 27617 
Pomerans. Mark. 5505 Knollwood Drive. Raleigh 27609 

WILSON 

Holland. James Eugene. (OPH) 1700 S. Tarboro Street. Carolina 
Clinic, Inc., Wilson 27893 



WHAT? WHEN? WHERE? 

In Continuing Education 



Please note: 1. The continuing Medical Education Programs at 
Bowman Gray, Duke, East Carolina and UNC Schools of Medi- 
cine, Dorothea Dix, and Burroughs Wellcome Company are ac- 
credited by the American Medical Association. Therefore CME 
prog"ams sponsored or cosponsored by these schools automatically 
qualify for AMA Category I credit toward the AMA's Physician 
Recognition Award, and for North Carolina Medical Society Cate- 





B.B- Plyler, Jr., C.L.U. 



Brent Plyler, C.L.U 



— Medical Clinics Only — 

High limit group Life and Disability Income 
insurance. Available only to medical clinics 
and their employees (not available to general 
public). Guarantee-issue (no medical) for five 
or more participants. Discount to Clinics 
whose manager is a member of MEDICAL 
GROUP MANAGEMENT ASSOCIATION. 




Plyler Financial Services 

P.O. Box 576 • Wilson, N.C. 27893 

Telephone (919)291-3333 



August 1981. NCMJ 



573 



1 



gory A credit. Where AAFP credit has be n requested or obtained, 
this also is indicated. 

2. The "place" and "sponsor" are indicated for a program only 
when these differ from the place and source to write "for informa- 
tion." 

September 15 

5th Annual Cape Fear Medical Symposium 

"Update in Infectious Diseases" 

Place: Bordeaux Motor Inn. Fayetteville 

Credit; 7 hours 

For Information: Mrs. Mary Henley. Fayetteville Area Health 

Education Center, P.O. Box 64699, Fayetteville, N.C., 28306 or 

919/323-1152, 

September 16 
"Cardiac Rehabilitation and Consequences of Stress" 
Place: Central Carolina Hospital, Sanford 
Credit: 15 hours 
Fee: $10 
For Information: R. S. Cline, M.D., 919/774-4111, Lee County 

Hospital, Sanford 27330 

September 25-26 

"Dermatology for the Non-Dermatologist" 

Place: Wilmington Hilton 

Credit: 7 hours 

Fee: $50 

For Information: W. B. Wood, M.D.. Office of Continuing Educa- 
tion. 231 McNider Building, UNC School of Medicine. Chapel 
Hill 27514 919-933-2118 

September 29-October 1 

"1981 Duke Cardiac Arrhythmia Course" 

Place: Rauch Conference Room, Rm. 15103 — Morris Bldg., Duke 

South 
Credit: 17 hours 
Fee: $175 
For Information: Galen Wagner, M.D., Box 31211, Duke Univ. 

Med. Ctr., Durham 27710 919-681-2255 



October 1-3 

"Natural Abilities and Perceived Worth: Rights. Values and Re- 
tarded Persons" 

12th Symposium on Philosophy and Medicine 

Place: Greenville 

For Information: Loretta Kopelman, ECU School of Medicine, 
Greenville 27834 919-757-4624 

October 1-4 

The 1981 Duke University Invitational Assembly for Advanced 

Urology 
"Diseases of the Lower Urinary Tract" 
Place: Pinehurst Hotel and Country Club 
For Information: David F. Paulson, M.D., Duke Univ. Med. Ctr., 

Durham 919-684-2033 

October 9 

"llth Annual Seminar in Medicine (Hypertension)" 

Place: Bowman Gray School of Medicine 

Credit: 6 hours 

Fee: $60 

For Information: Emery C. Miller, M.D., 300 S. Hawthorne Road, 

Bowman Gray School of Medicine, Winston-Salem 27103 919- 

748-4450 

October 21-22 

"Office Treatment of Depression" 
Place: Carolina Inn, Chapel Hill 
Fee: $20 

For Information: J. Ingram Walker, M.D., Dept. of Psychiatry, 508 
Fulton Street, Durham 27705 919-286-4011, Ext. 6651 

October 22 

"Headache" 

Place: Burroughs Wellcome, Research Triangle Park 

Credit: 4 hours 

Fee: None 

For Information: Mrs. Sandy Foster 919-541-9090 






IF YOUR PATIENT TELLS US 
SHE'S PREGNANT, 

SHE WON'T GET A LECTURE. 
SHE'LL GET HELP. 



Free, professional problem pregnancy counseling. 
If she can't come to us, we'll come to her. 

The Children's Home Society of North Carolina, Inc. 



Asheville (704) 258-1661 Fayetteville (919) 483-8913 

Chapel Hill (919) 929-4708 Grefnsboro (919) 274-1538 |ibm»- 

Charlotte (704) 534-2854 Greenville (919) 752-5847 ^"^ 

Wilmington (9l9) 799-0655 , 



Member Child Welfare League of America. Founded 1902. 



574 



Vol. 42, No 



i 



October 22-23 
"Pediatric Pathology Club" 
Place: Duke Univ. Medical Center 
Credit: 16 hours 
Fee: $120 

For Information: William D. Bradford, M.D.. Box 3712, Duke 
Univ. Med. Ctr., Durham 27710 

October 25-26 

"Technique of Pacemaker Implantation & New Types" 

Place: Bowman Gray School of Medicine 

Credit: 9 hours 

Fee: $60 

For Information: Emery C. Miller, M.D., 300 South Hawthorne 

Street, Bowman Gray School of Medicine, Winston-Salem 27104 

919-748-4450 

October 30-31 

"Understanding and Treatment of the Aggressive Adolescent" 

Place: Searle Center for Continuing Education, Duke University 
Medical Center 

Credit: 1 1 hours 

Fee: $175 

For Information: J. Ingram Walker, M.D., Duke University Medi- 
cal Center 919-684-2711. Ext. 303 

October 30-31 

14th Annual Malignant Disease Symposium on Abdominal and 

Extremity Tumors" 
iPlace: UNC School of Medicine 
Credit: 11 hours 
Fee: $100 
For Information: Mimi Minkoff, Cancer Research Center, Box 30 

MacNider BIdg, Chapel Hill 27514 

October 31 -November 2 

"Advanced Cardiac Life Support Instructors Course" 

Place: Bowman Gray School of Medicine 

Credit: 22 hours ] 

;Fee: $300 

For Information: Emery C. Miller. M.D. 919-748-4450 

November 6 

I'Alumni Scientific Sessions" 
place: Bowman Gray School of Medicine 
Ipredit: 6 hours 
jFee: None 
For Information: Emery C. Miller, M.D. 919-748-4450 

II 

I November 20-23 

'('Multiple Sclerosis for Practicing Physicians" 

^lace: Duke University Medical School 

Credit: 9 hours 

Fee: $10 

.=or Information: Allen D. Roses, M.D. 919-683-6274 



IN CONTIGUOUS STATES 

August 10-11 

'Antibiotic Review — 1981" 
'lace: Washington, D.C. 

or Information: Sandy McMillan, 67 Peachtree Park Dr., Suite 
22 1 -D, Atlanta, Ga. 30309 

September 3-4 

''Advances in Clinical Nutrition" 

'lace: Sea Pines Resort, Hilton Head Island, South Carolina 
-or Information: Julie Bishop, A.S.P.E.N., Suite 810. 1025 Ver- 
mont Avenue, N.W., Washington, D.C. 20005 202-638-5881 

September 25 
'Environmental Insults to the Fetus and the Newborn" 
'lace: Richmond Hyatt, Richmond, Va. 
■or Information: Kathy E. Johnson 804-786-0494 

The items listed in the above column are for the six months 
nmediately following the month of publication. Requests for listing 
hould be received by "WHAT? WHEN? WHERE?", P.O. Box 
7167, Raleigh 2761 1 , by the 10th of the month prior to the month in 
/hich they are to appear. A "Request for Listing' ' form is available 
n request. 

>UGUST 1981, NCMJ 



AUXILIARY TO THE NORTH CAROLINA 
MEDICAL SOCIETY 



INAUGURAL ADDRESS 

May 8, 1981 

Life Is a Celebration 

Today is a celebration! It is a celebration of the 
achievements of a year gone by too fast, and the 
promises of the one to come. More than that, it is the 
celebration of the last of the three Ann's. Today marks 
the beginning of the end of Ann-era. 

Does it appear that during the coming year I am 
suggesting we celebrate everything — from the open- 
ing of a manhole to the closing of a door? Heavens, no! 
I firmly believe in honoring the ceremonies of life with 
fireworks, bands, presents, balloons, the whole bit. 
They are the warp and woof of the fabric which 
weaves the family together. However, we have much 
serious business to address in this organization with 
very little time for champagne breaks. I am suggesting 
that we approach our goals in the medical auxiliary 
with enthusiasm. "Life is a Celebration" implies that 
life is important for everyone — regardless of age or 
gender or physical condition. Life as a celebration 
conveys hope, which is one of the best medicines in 
the world. Certainly our physician husbands are dis- 
pensers of hope, and if we as auxilians are to work in 
partnership with them to augment their capacity to 
keep people healthy, we too should be dispensers of 
hope. 

It is very difficult to achieve our goals without 
members, but in order to attract and keep members we 
have to make it worth their while. This requires plan- 
ning with strong programming and interesting, feasi- 
ble, pertinent projects. In no way do I discount the 
social aspects of medical auxiliary, but if all we can 
offer is a cup of tea and over-the-fence gossip we will 
not challenge those to join whose available time is as 
precious as diamonds. If the theme for this year ap- 
pears to have overtones of Pollyanna-ism, I will agree 
to this extent: I optimistically believe that there is 
good in this organization for every physician's wife as 
an avenue for her talents, her concerns and interests, 
her self-image and well-being. 

Obviously I have not been rendered speechless by 
the honor which has been bestowed on me this day — 
and I do recognize it as an honor to be chosen out of so 
many outstanding women — but naturally I am over- 
whelmed by the magnitude of my responsibilities. 
There will be times when I ask myself (and others): 
How did I manage to get myself into this ridiculous 
situation? Those times will serve to keep me humble, 
and they certainly will be a constant reminder to me of 
how grateful I am for the consummate skills, the en- 
durance, the dedication and the support of those who 
have preceded me. Ann Rollins has passed on a 
well-tuned machine with a high EPA rating, fueled as 



575 



much on laughter and the joy of shared experience as 
anything else. I shall miss her. What I bring to you as 
your president is knowledge bom of the shared ex- 
perience and many, many years in the "field." Occa- 
sionally it may pass as wisdom. Feel free to avail 
yourselves of it because we can't have a party if no- 
body comes. 

Mrs. Hampton (Anne) Hubbard 
State Auxiliary President 
Clinton, N.C. 



News Notes from the— 

BOWMAN GRAY SCHOOL 
OF MEDICINE 

WAKE FOREST UNIVERSITY 



Dr. Kenneth A. Gruber, a Bowman Gray School of 
Medicine researcher who was instrumental last year in 
the discovery of a new hormone, has been given a 
Research Career Development Award. 

The five-year award is from the National Heart, 
Lung and Blood Institute, and is one of the most highly 
regarded training funds available to academic medi- 
cine. 

Gruber, a research associate professor of medicine 
(nephrology), will use the award to examine in much 
greater detail the structure and function of the newly 
discovered hormone, which has been named endoxin. 

The award also will enable Gruber to take a sabbati- 
cal in 1982 to work with researchers at the Cardiovas- 
cular Institute of the University of Iowa, considered to 
be the foremost center for study of central nervous 
system control of the cardiovascular system. 

Gruber's new award will permit him to further his 
work on deciphering the structure of endoxin. If it 
eventually is shown that endoxin is a cause of human 
essential hypertension, and if the structure of the 
hormone is known, then pharmaceutical companies 
may be able to develop drugs which block the hor- 
mone's harmful effects. 

Gruber plans further study of the role of the brain in 
releasing endoxin, to study where in the body endoxin 
is made and to continue research on salt's role in 
promoting the production of endoxin. 

Gruber joined the Bowman Gray faculty in 1976. He 
holds both the B.A. and Ph.D. degrees from New 
York University. 



The Bowman Gray School of Medicine has been 
awarded a biomedical research support grant for 
$150,820 by the Division of Research Resources of the 
National Institutes of Health. 

While this is the 20th consecutive year that Bowman 
Gray has received such a grant, school officials view 
the most recent grant as especially important. 

The grant provides considerable flexibility in the 



576 



CyCL4PEN-lV(cyclacillin) 

Indtcohons 

Cyciacillin hoi less in vitro activity than other drugs in the ampicHHn 
class and its use should be confined to these indications^ Treatment 
of the following infections: 
RESPIRATORY TRACT 

Tonsillitis and pharyngitis caused by Group A beta-hemolytic 

streptococci 

Bronchitis and pneumonia caused by S. pneumoniae (formerly 

D pneumoniae) 

Otitis medio caused by S, pneumonioe {formerly D, 

pneumoniae) and H. influenzae 

Acute exocerbotion of chronic bronchitis caused by H. in- 
fluenzae' 

'Though climcol improvement has been shown, bacteriologic 

cures cannot be expected in oil patients with chronic respi- 

rotory diseose due toH. influenzae. 
SKIN AND SKIN STRUCTURES (integumentary) infections caused 
by Group A beta-hemolytic streptococci and staphylococci, non- 
penicillinase producers. 

URINARY TRACT INFECTIONS caused by E. co/. and P. mirabilis- 
(This drug should not be used in any E. co/i and P. mirabilis infec- 
tions other fhon urinary tract.) 

NOTE: Perform cultures ond susceptibility tests initially and dur- 
ing treotment to monitor effectiveness of therapy and susceptibil- 
ity of boctena. Therapy moy be instituted prior to results of sen- 
sitivity testing. 

Contraindications Contromdicated in individuols with history of 
□ n otlergic reaction to penicillins 

Warnings Cyciacillin should only be prescribed for the indica- 
tions listed herein. 

Cyciacillin has less in vitro activity than other drugs of the 
ompicillin class. However, clinical trials demonstrated it is ef- 
ficacious for recommended indications 

Serious and occasional fatal hypersensitivity (anaphylactoid) 
reocttons have been reportea in patients on penicillin Al- 
though anaphylaxis is more frequent following parenteral 
use, it has occurred in patients on oral penicillins. These reac- 
tions are more apt to occur in individuals with history of sen- 
sitivity to multiple allergens There are reports of patients 
with history of penicillin hypersensitivity reactions who ex- 
perienced severe hypersensitivity reactions when treated 
with a cephalosporin Before penicillin therapy, carefully in- 
quire about previous hypersensitivity reoctions to penicillins, 
cephalosporins and otner ollergens If allergic reaction oc- 
curs, discontinue drug and initiate appropriate therapy. Seri- 
ous anaphylactoid reactions require immediate emergency 
treatment with epinephrine Oxygen, l,V steroids, airwoy 
management, including intubation, should also be adminis- 
tered as indicated. 

Precautions Prolonged use of antibiotics may promote over- 
growth of nonsusceptible organisms. If superinfection occurs, take 
appropriate measures. 

PREGNANCY Pregnancy Category B Reproduction studies per- 
formed in mice and rots at doses up to 10 times the human dose 
revealed no evidence of impaired fertility or harm to the fetus due 
to cyciacillin There ore, however, no adequate ond well- 
conlrolled studies in pregnont women. Because animal reproduc- 
tion studies are not olways predictive of human response, use this 
drug during pregnancy only if clearly needed, 
NURSING MOTHERS. It is not known whether this drug is excreted 
in humon milk Because mony drugs are, exercise coution when 
cyciacillin is given to a nursing womon. 

Adverse Reactions Oral cyciacillin is generally well tolerated. As 
with other penicillins, untoword sensitivity reactions are likely, 

forficularly m those who previously demonstroted penicillin 
ypersensitivity or with history of allergy, asthma, ho/ fever, or 
urticorio Adverse reoctions reported with cyclocillin: diarrhea (in 
Qpproximotely 1 out of 20 patients treoted), nouseo and vomiting 
(in approximately 1 in 50), ond skin rash {in opproximotely t in 
60). Isolated instances of heodache, dizziness, abdominal poin, 
voginitis, and urticorio hove been reported. (See WARNINGS) 
Other less frequent adverse reoctions which may occur and ore 
reported with other penicillins ore anemia, thrombocytopenia, 
thrombocytopenic purpura, leukopenio, neutropenio and 
eosinophilia These reactions are usually reversible on discontinu- 
ation of therapy 

As with other semisynthetic penicillins, SGOT elevations hove been 
reported 

As with antibiotic therapy generally, continue treatment at least 
48 to 72 hours ofter patient becomes osymptomatic or until bacte- 
rial erodicotion is evidenced. In Group A beta-hemolytic strep- 
tococcal infections, ot least 10 days' treatment is recommended to 
guard ogoinst risk of rheumatic fever or glomerulonephritis. In 
chronic urinory tract infection, frequent bacteriologic and clinical 
appraisal is necessory during therapy and possibly for several 
months after Persistent infection moy require treatment for sev- 
eral weeks. 

Cyclocillin is not indicated in children under 2 months of age. 
Patients with Renal failure Cyclocillin may be safely administered 
to patients with reduced renol function Due to prolonged serum 
half-life, patients with vonous degrees of renal impairment may 
require change in dosage level (see DOSAGE AND ADMINISTRA- 
TION in package insert) 
Dosage (Give m equally spaced doses) 



INFECTION 


ADULTS 




CHILDREN' 


fiespirofory 
Tract 










Tonsillitis & 
Pharyngitis 


250 


T.gq.i.d. 




body weight ■ 20 kg 
(44 lbs) 125 mg q.i.d. 


Bronchitis and 








body weight > 20 kg 
(44 lbs) 250 mg q.i.d. 


Pneumonia 










Mild or 
Moderate 


250 r 


ngq i d. 




50 mg/kg/doy q id. 


Infections 










Chronic 
Infections 


500 r 


ng q 1 d 




100 mg/kg/doy q..,d. 


Otitis Media 


250 n 
q.i.d 
250 n 
q.i.d 


ng to 500 


■"9 


50 to 100 mg/kg/doyt 


Skin & Skm 
Structures 


ig to 500 

t 


^9 


50 to 100 mg/kg/doyt 



Urinory Tract 500 mg q,i d. 100 mg/itg-'doy 

'Dosage should not result in o dose higher than thot for adults. 
Tdepending on severity 



Wyeth Laboratories 

' ' i Philadelphia, Pa 19101 



\AJ' 



Half the dose 
is absorbed in 9 minutes! 

compared to 32 minutes for ampicillin* 




Mean blood levels in mcg/ml after 250 nng 
cyclacillin single oral dose 




12 3 4 5 

Time (hours after administration) 



I • Rapid, virtually complete absorption fronn Gl tract 
I • Exceptionally high peak blood levels — 3 times 

greater than ampicillin (Clinical efficacy may not 

always correlate with blood levels.) 
• Rapidly excreted unchanged in urine - 

IV2 times faster than ampicillin 

*Based on T V2 values for single oral doses of 500 mg cyclacillin 
tablet and 500 mg ampicillin capsule. Data on file, V^yeth Laboratories 

Copyright© 1980, Wyeth Laboratories. All rights reserved. 



Fewer episodes of diarrhea and rash 
than with ampicillin in studies to date. 

Efficacy proven in the treatment 
of bronchitis, pneumonia, and upper 
respiratory infections.^ 

In 117 patients, 73 with bronchitis/pneumonia 
caused by S. pneumoniae and 44 with streptococcal 
sore throat caused by Group A beta-hemoiytic 
streptococcus, CYCLAPEN'"-W achieved a clinical 
response rate of 100%! Bacterial eradication was 
95% and 86% respectively. 

tDuc to susceptible organisms. 

See important information on facing page. 



ca"~ — 



I I • 1 1 • \ 250 and 500 mg Tablets 

(cyclacillin) --e^i-" ^^ 

more than ust spectrum >vV^ 



support of research, which is particularly important in 
view of expected cutbacks in other federal grants 
available for biomedical research. 

The purpose of such grants is to provide additional 
support for institutions with already established and 
productive research programs. 



Five members of the Bowman Gray faculty have 
been promoted to the rank of full professor. 

They are Dr. Robert L. Dixon, radiology (physics): 
Dr. Phillip M. Hutchins, physiology; Dr. William B. 
Lorentz Jr., pediatrics; Dr. Timothy C. Pennell, 
surgery; and Dr. Robert A. Turner Jr.. medicine 
(rheumatology). 

They were among 33 faculty members who received 
promotions effective July 1. 



Five Bowman Gray faculty members have been 
presented Faculty Foreign Travel Awards to support 
their participation in international meetings this sum- 
mer. 

The recipients are Dr. Laurence A. Bradley, assis- 
tant professor of psychology; Dr. Kenneth A. Gruber, 
research assistant professor of medicine; Dr. Philip 
W. Landfield, assistant professor of physiology; Dr. 
Douglas S. Lyles, assistant professor of microbiology 
and immunology; and Dr. Jack W. Strandhoy, as- 
sociate professor of pharmacology. 

Bradley will speak at the Third World Congress on 
Pain in Edinburgh, Scotland. Gruber and Standhoy 
will present scientific papers at the Eighth Interna- 
tional Congress of Nephrology in Athens, Greece. 

Landfield will participate in the International Con- 
gress of Gerontology in Hamburg, Germany. 

Lyles will present a paper at the Fifth International 
Congress of Virology in Strasbourg. France. 



Dr. Timothy C. Pennell, professor of surgery, was 
presented the Award for Teaching Excellence during 
Bowman Gray's annual awards ceremony. The award 
includes an engraved plaque and a monetary prize to 
be used toward the individual's further academic en- 
richment. 

Candidates for the award are nominated by the 
medical students and selected by a committee com- 
posed of representatives of the medical school ad- 
ministration, academic faculty and student body. 

The senior class also honored Dr. Pennell by dedi- 
cating the yearbook to him. 

Basic Science Teaching Awards were presented to 
Dr. Walter J. Bo, professor of anatomy; and Dr. 
Robert W. Prichard, professor and chairman of the 
Department of Pathology. 

Dr. Barry Hackshaw, assistant professor of medi- 
cine (cardiology), and Dr. Richard B. Urban, assistant 
professor of obstetrics and gynecology, received cita- 
tions for excellence in clinical teaching. 

John C. Sowers was presented the Faculty Award, 



the highest award that can be bestowed on a medical 
student by the Bowman Gray faculty. The award, 
which includes an engraved plaque, is presented an- 
nually to a graduating medical student who has dem- 
onstrated outstanding scholarship and character dur- 
ing four years of medical school. 

House Officer Teaching Awards were presented to 
Drs. Julia M. Cruz and Daniel M. Camden, residents 
in medicine. 



Dr. Julia Cruz, resident in medicine, has received 
the 1981 Osier Award, presented each year by the 
Department of Medicine to a resident in that depart- 
ment who best exemplifies "The ideal of patient care 
and scholarship" set by Dr. William Osier. 



Two new members of the Bowman Gray School of 
Medicine faculty have been appointed. 

They are Dr. Ernest H. Kawamoto, assistant pro- 
fessor of pathology; and Dr. Roger A. Horton, in- 
structor in dentistry. 

Kawamoto holds the M.D. degree from the Univer- 
sity of Colorado School of Medicine and completed 
residency training in anatomic and clinical pathology 
at the University of Colorado Medical Center. He 
took a fellowship in surgical pathology and cytology at 
the Medical College of Virginia. 

Horton is a graduate of the University of Pittsburgh 
School of Dental Medicine, where he received the 
D.M.D. degree. He completed a residency in general 
practice dentistry at the University of Colorado 
Health Sciences Center School of Dentistry and com- 
pleted a clinical fellowship in the Department of Den- 
tistry at Bowman Gray. , 



Dr. Henry Drexler, professor of microbiology, has 
been elected president of the North Carolina Branch 
of the American Society for Microbiology. 



Dr. Clara M. Heise, assistant professor of radiology 
(biochemistry) has been re-elected as a member-at- 
large to the Executive Committee of the Clinical 
Radioassay Society for 1981-82. 



Dr. Eugene R. Heise, associate professor of micro- 
biology, has been elected to a three-year term as 
councillor-at-!arge for the American Association for 
Clinical Histocompatibility Testing. He also is chair- 
man of the Publications Committee. 



Dr. Julian F. Keith, professor and chairman of the 
Department of Family and Community Medicine, has 
been appointed to the United States Pharmacopeia 
Advisory Panel on Family Practice. He also has been 
elected president of the Board of Directors of the 
Child Guidance Clinic of Forsyth County, Inc. 



578 



Vol. 42, No. 8 



Dr. Laurence B. Leinbach, professor of radiology, 
was elected president of the Eastern Radiological So- 
ciety during the organization's annual meeting. 



Dr. Richard C. Proctor, professor and chairman of 
the Department of Psychiatry and Behavioral Medi- 
cine, has been reappointed chairman of the Ethics 
Committee of the North Carolina Branch of the 
American Psychiatric Association. 



Dr. John R. Ureda, instructor in community medi- 
cine, has been re-elected chairman of the Forsyth 
County Health Education Council for 1981-82. 



News Notes from the— 

DUKE UNIVERSITY MEDICAL CENTER 



Two scientists at the medical center. Dr. Irwin 
Fridovich and Dr. Wolfgang K. Joklik, were named to 



the National Academy of Sciences, generally ac- 
claimed as the nation's most prestigious society for 
scientists of all disciplines. 

Fridovich is James B. Duke Professor of Biochem- 
istry. He and his laboratory colleagues discovered 
sulfite oxidase, the enzyme which protects the body 
from the catastrophic effects of sulfite. He and his 
colleagues also discovered superoxide dismutasse, 
another family of enzymes that protect cells from the 
toxic effects of oxygen, such as damage to membranes 
and DNA. 

Joklik is James B. Duke Professor of Microbiology 
and Immunology and chairman of the department. He 
is also director of basic research for the Duke Com- 
prehensive Cancer Center. Joklik's research interests 
have included smallpox virus, RNA tumor viruses and 
interferon, which he has studied for 16 years. 



Duke physicians have begun tapering a group of 
epileptics off their medication to determine how long 
epileptics need to stay on medication once seizures 
are under control. The projected 200 to 500 partici- 



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is the presenting 

symptom . . . 




V ■- 0, 



^p 




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. . in the functional bowel/irritable bowel 
lyndrome* 

fe sure to specify 




entyl 



® 



mg capsules, 20 mg tablets, 
mg/5 ml syrup, 10 mg/ml injection 



icyclomine 
ydrochloride USP) 




'^J?.fii.k)rT)^i^foenAe. OA- LUtiX:Ss/b 



iecause: 



) The Bentyl molecule is a product of original Merrell research. 

) At Merrell Dow, Bentyl must go through 140 checkpoints/tests from its synthesis 
through the packaging of the final product. 

) Bentyl bioavailability of tablets, capsules, syrup and injectable is evidence of its 
prompt absorption. 

Bentyl helps control abnormal gastrointestinal motor activity with minimal 

antlCnOiinergiC side etteCtS. (See warnings, contraindications. Precautions, and Adverse Reactions on next page.) 

\ The bioequivalence of the oral dosage forms permits a choice of tablet, capsules, 
or syrup that satisfies patient's dosage preferences. 

( f Significant pharmacologic effect in the distal colon compared to placebo,'' shows 
how Bentyl controls abnormal motor activity in the irritable colon patient.* 



I ■ ■ jrug has been classified "probably" effective for this indication. 



Merrell Dow 

le ence: 

Jwdhury AR and Lorber SH: Personal communication, 1980, 



(See Product Infomiation on the next page before prescribing Bentyl,) 

'^' ,gh ttie dose of Bentyl used to sfiow pharmacologic effect was 50 mg, which is a higher single dose than that permitted in the labeling, the dose was considered justified, 
ri he recommended daily dose of miectable Bentyl is 20 mg (2 ml) every 4 to 6 hours Thus, in 8 hours, a patient could receive a total of 60 mg I M. and, at that time, as a result 

- i^ sustained plasma levels from the 20 mg iniections at and 4 hours, might show an even higher plasma level than occurs after a single 50 mg dose. Presumably the same 

-ii,.iacoiogic effect would follow. These observations do not constitute evidence of efficacy 



Bentyl 



® 



(dicyclomine hydrochloride USP) 

Capsules, Tablets, Syrup. Injection 
AVAILABLE ONLY ON PRESCRIPTION 
Brief Summary 



INDICATIONS 

Based on a review of this drug by ttie National Academy of 
Sciences-National Researcfi Council and/or olfier information. FDA 
has classified the following indications as "probably" effective: 

For the treatment of functional bowel/irrilable bowel syn- 
drome (irritable colon, spastic colon, mucous colitis) and 
acute enterocolitis 

THESE FUNCTIONAL DISORDERS ARE OFTEN RELIEVED 
BY VARYING COfVlBINATIONS OF SEDATIVE, REASSUR- 
ANCE, PHYSICIAN INTEREST, AMELIORATION OF EN- 
VIRONfVlENTAL FACTORS. 
For use in the treatment of infant colic (syrup). 

Final classification of the less-than-effective indications 
requires further investigation. 



CONTRAINDICATIONS: Obstructive uropathy (for example, bladder 
neck obstruction due to prostatic hypertrophy), obstructive disease 
of the gastrointestinal tract (as in achalasia, pyloroduodenal 
stenosis), paralytic ileus, intestinal atony of the elderly or debili- 
tated patient, unstable cardiovascular status m acute hemorrhage, 
severe ulcerative colitis: toxic megacolon complicating ulcerative 
colitis: myasthenia gravis. 

WARNINGS: In the presence of a high environmental temperature, 
heat prostration can occur with drug use (fever and heat stroke due 
to decreased sweating). Diarrhea may be an early symptom of 
incomplete intestinal obstruction, especially in patients with ileos- 
tomy or colostomy In this instance treatment with this drug would 
be inappropriate and possibly harmful Bentyl may produce drow- 
siness or blurred vision. In this event, the patient should be warned 
not to engage in activities reguirmg mental alertness such as 
operating a motor vehicle or other machinery or perform hazardous 
work while taking this drug There are rare reports of infants, 6 
weeks of age and under, administered dicyclomine hydrochloride 
syrup, who have evidenced respiratory symptoms (breathing diffi- 
culty, shortness ol breath, breathlessness, respiratory collapse, 
apnea), as well as seizures, syncope, asphyxia, pulse rate fluctua- 
tions, muscular hypotonia, and coma The above symptoms have 
occurred within minutes of ingestion and lasted 20 to 30 minutes 
The timing and nature of the reactions suggest that they were a 
conseguence of local irritation and or aspiration rather than a direct 
pharmacologic effect. No known deaths or permanent adverse 
effects have been reported. Bentyl syrup should be used with 
caution in this age group 

PRECAUTIONS: Although studies have failed to demonstrate ad- 
verse effects of dicyclomine hydrochloride in glaucoma or in 
patients with prostatic hypertrophy, it should be prescribed with 
caution in patients known to have or suspected of having glaucoma 
or prostatic hypertrophy. 
Use with caution in patients with 
Autonomic neuropathy. Hepatic or renal disease. Ulcerative coli- 
tis Large doses may suppress intestinal motility to the point 
of producing a paralytic ileus and the use of this drug may 
precipitate or aggravate the serious complication of toxic 
megacolon 
Hyperthyroidism, coronary heart disease, congestive heart fail- 
ure, cardiac arrhythmias, and hypertension. 
Hiatal hernia associated with reflux esophagitis since anti- 
cholinergic drugs may aggravate this condition 
Do not rely on the use of the drug in the presence of complication of 
biliary tract disease. Investigate any tachycardia before giving 
anticholinergic (atropine-like) drugs since they may increase the 
heart rate. With overdosage, a curare-like action may occur. 
ADVERSE REACTIONS: Anticholinergics, antispasmodics produce 
certain effects which may be physiologic or toxic depending upon 
the individual patient's response The physician must delineate 
these. Adverse reactions may include xerostomia, urinary hesi- 
tancy and retention: blurred vision and tachycardia; palpitations, 
mydriasis, cycloplegia, increased ocular tension, loss ol taste, 
headache: nervousness, drowsiness, weakness: dizziness, 
insomnia; nausea: vomiting, impotence, suppression of lactation; 
constipation: bloated feeling: severe allergic reaction or drug 
idiosyncrasies including anaphylaxis: urticaria and other dermal 
mamleslations. some degree of mental confusion and-or excite- 
ment, especially in elderly persons: and decreased sweating With 
the miectable form there may be a temporary sensation of light- 
headedness and occasjonally local irritation 
DOSAGE AND ADMINISTRATION: Dosage must be adjusted to indi- 
vidual patient's needs 
Usual Dosage 

Bentyl 10 mg capsule and syrup: ^du//s 1 or 2 capsutes or tea- 
spoonfuls syrup three or four times daily. Children 1 capsule or 
teaspoonful syrup three or four times daily Infants V2teaspoon- 
ful syrup three or lour times daily (Dilute with equal volume 
of water ) 
Bentyl 20 mg.: Adults: 1 tablet three or four times daily. 
Bentyl Injection; Adults 2 ml. (20 mg.) every four to six hours 
intramuscularly only 
NOT FOR INTRAVENOUS USE. 
MANAGEMENT OF OVERDOSE: The signs and symptoms of over- 
dose are headache, nausea, vomiting, blurred vision, dilated 
pupils, hot, dry skin, dizziness, dryness of the mouth, difficulty m 
swallowing, CNS stimulation Treatment should consist of gastric 
lavage, emetics, and activated charcoal Barbiturates may be used 
either orally or intramuscularly for sedation but they should not be 
used it Benlyl with Phenobarbital has been ingested If indicated, 
parenteral cholinergic agents sucti as Urecholine^' (bethanecol 
chloride USP) should be used 
Product Information as of July, 1980 
Injectable dosage forms manufactured by 
CONNAUGHT LABORATORIES, INC 
Swiftwater. Pennsylvania 18370 or 
TAYLOR PHARIVIACAL COfytPANY 
Decatur, Illinois 62525 tor 



Merrell 



MERRELL DOW PHARMACEUTICALS INC 

Subsidiary of The Dov^ Chemical Company 

Cincinnati. OH 4521 5 U.S.A. 

MNQ-7U 



1 -7052 ( Y36BC) 



pants in the study will come from Duke's Clinical 
Research Seizure Clinic and a similar clinic at North 
Carolina Memorial Hospital. 

Thus far, approximately 30 adolescent epileptics 
seen at the Duke clinic have completed a six-week 
drug-tapering program. Dr. Stanley J. Rothman, an 
associate professor of pediatrics and chief of Duke's 
pediatric neurology division, is directing the study. 



Dr. Robert J. Ruderman, assistant professor of or- 
thopaedic surgery and pediatrics, was one of six or- 
thopaedic surgeons chosen to receive a fellowship 
from the American, British and Canadian Exchange. 

The fellowship sponsored six weeks of study in 
Great Britain. He visited British medical centers and 
hospitals March 21-May 3. 



Dr. Nicholas Georgiade, professor and chief of the 
division of plastic, maxillofacial and oral surgery, was 
one of 10 international speakers invited to meet with 
Egyptian plastic surgeons in Cairo in May. 

The conference was part of the International 
Esthetic Society meeting. 



Dr. James L. Ringo, a research associate in 
ophthalmology, received a Fulbright Fellowship from 
the Mutual Educational Exchange Program. Ringo 
will study at the University of Amsterdam from 
January through June, 1982. 

He received the Fulbright for study of "Simultane- 
ous Measurer of the Contrast Sensitivity Functions of 
Single Visual Neurons and the Whole Animal in 
Awake Monkeys." 



Captain William H. Briner, director of the medical 
center's radiopharmacy and nuclear laboratory, re- 
ceived a special citation from the Food and Drug Ad- 
ministration (FDA). 

Briner, a retired captain in the United States Public 
Health Service received the citation May 22 in Wash- 
ington, D.C. 

The award cited Briner's "outstanding contribu- 
tions to the FDA as a member and consultant to the 
agency's radiopharmaceutical drugs advisory com- 
mittee." 



GRANTS AND CONTRACTS 

Robert Machemer, professor and chairman of the 
Department of Ophthalmology, was awarded a 
$103,692 grant from the National Eye Institute. 
Machemer's study is "Vitrectomy Through the Pars 
Plana." 

Peter Cresswell, associate professor of immunol- 
ogy, received a $62,000 grant from the National Insti- 
tute of Allergy and Infectious Disease for "Molecular 
Studies of the Mixed Lymphocyte Response." 

Vol. 42, No. 8 



I 



Walter R. Guild, professor in the Department of 
Biochemistry, received a $44,480 grant from the Na- 
tional Institute of General Medical Sciences. He is 
studying "Pneumococcal Phage as Genetic Tools." 
Robert L. Hill, professor and chairman of the De- 
partment of Biochemistry, was awarded a $408,673 
research service award from the National Institute of 
General Medical Sciences. 

William L. Holman, in the Department of Surgery, 
received a $16,468 award from the National Heart, 
Lung and Blood Institute to study arrhythmias. 

Stephen F. Vogel, professor of pathology, received 
a $12,781 grant from the National Institute on Aging 
for the study of "Biological Approaches to Demen- 
tia." 

Erwin Fridovich, professor of biochemistry, re- 
jCeived a $100,947 grant from the National Institute of 
iGeneral Medical Sciences, for the study of "The Biol- 
ogy of Superoxide Radical and of the Superoxide." 
Arno L. Greenleaf, assistant professor of biochem- 
istry, received an $83,570 grant from the National 
Institute of General Medical Sciences for the study of 
"Biochemical Genetics of Drosophila RNA Poly- 
merase II." 

Edward W. Holmes Jr., associate professor in the 
division of rheumatic and genetic disease, was 
awarded an $84,971 grant from the National Institute 
of Arthritis, Metabolism and Digestive Diseases. 
Holmes is studying "Purine Metabolism in Gout." 

David C. Sabiston Jr., James B. Duke Professor of 
Surgery and chairman of the department, received a 
$163,792 grant from the National Heart, Lung and 
Blood Institute for the study of "Coronary Insuffi- 
ciency and Myocardial Revascularization." 

Avis L. Sylvia, assistant medical research professor 
:)f physiology, was awarded a $77,197 grant from the 
National Institute on Aging. The grant will support 
itudy of "Brain Function and Oxidative Metabohsm 
During Aging." 

William Hylander, associate professor of an- 
hropology and anatomy, received a $56,387 grant 
"rom the National Institute on Dental Research for 
'Strain in the Facial Bones of Macaca Fascicularis." 
John M. Corless, associate professor of anatomy 
ind associate in ophthalmology, received a $91,307 
;rant from the National Eye Institute. Corless will use 
he grant to support research in "Retinal Rod Photo- 
eceptor Membrane Structure/Function." 

Doyle G. Graham, clinical associate professor of 
lathology, received a $78,488 grant from the National 
nstitute of Environmental Health Sciences for the 
tudy of "Environmental Toxin-Induced Neurofila- 
nent Neuropathy." 

George L. Maddox, director of the Center for the 
itudy of Aging and Human Development, received a 
106,231 grant from the National Institute on Aging 
or the study of "Behavior and Physiology in Aging." 
Wolfgang K. Joklik. chairman and professor of the 
)epartment of Microbiology and Immunology, re- 
eived a $42,561 research grant from the National 



Cancer Institute. Joklik is studying "Virus- and Cell- 
Inhibitory Activity of Interferon." 

William S. Lynn Jr., professor in the division of 
pulmonary medicine, was awarded a $70,790 grant 
from the National Heart, Lung and Blood Institute for 
the study of "Structure, Source and Functions of 
Alveolar Glycoprotein." 

Thomas C. Vanaman, professor in the division of 
microbiology, was awarded a $101, 021 grant from the 
National Institute of Neurological and Communica- 
tive Disorders and Stroke for the study of "Brain 
Specific Proteins in Nerve Function." 

S. Clifford Schold Jr., in the Division of Neurology, 
was awarded a $30,910 grant from the National Insti- 
tute of Neurological and Communicative Disorders 
and Stroke for "Growth and Treatment of Human 
Gliomas in Athymics." 

Ronald B. Corley, assistant professor in the division 
of immunology, received a $64,268 grant from the 
National Institute of Allergy and Infectious Diseases 
for "Helper T Cells: Comparison of T-T and T-B 
Interaction." 

David C. Richardson, associate professor in the 
Department of Biochemistry, received a $109,739 
grant from the National Institute of General Medical 
Sciences for the Study of "Crystallographic Analysis 
of Protein Structures." 

Sheldon R. Pinnell, professor in the Division of 
Dermatology, was awarded an $89,597 grant from the 
National Institute of Arthritis, Metabolic and Diges- 
tive Diseases for the study of "Collagen Biosynthesis 
in Human Skin Fibroblasts." 

John W. Gutknecht, associate professor of physiol- 
ogy, received a $32,385 grant from the National Insti- 
tute of General Medical Sciences for study of "Acid/ 
Base Transport Through Lipid Bilayer Membranes." 

John C. Cambier, assistant professor of immunol- 
ogy, received a $34,286 grant from the National Insti- 
tute of Allergy and Infectious Diseases to study "The 
Molecular Biology of B Cell Tolerance." 

Richard S. Metzgar, professor in the division of 
immunology, received an $82,792 grant from the Na- 
tional Institute of Arthritis, Metabolic and Digestive 
Disease for "Immunological Studies of Primate Mem- 
brane Antigens." 

Tai-Shih Hsieh, in the Department of Biochemistry, 
received a $115,513 research grant from the National 
Institute of General Medical Sciences to study "DNA 
Topoisonmerase: Function and Mechanism." 

Richard O. Burns, professor in the division of 
microbiology, was awarded a $56,137 grant from the 
National Institute of General Medical Sciences for the 
study of "Molecular Mechanisms of Biological Con- 
trol." 

Robert D. Nebes, associate medical research pro- 
fessor, received a $39,862 grant from the National 
Institute on Aging for "Age and Selective Attention in 
Visual Search." 

Eugene D. Day, professor in the division of micro- 
biology, received a $63,844 grant from the National 
Institute of Neurological and Communicative Disor- 



UGUST 1981. NCMJ 



583 



ders and Stroke for "Studies of Glial Cell Membranes 
and Myelin."" 

George W. Brumley , professor in the Department of 
Pediatrics, received a $37,836 grant from the National 
Heart, Lung and Blood Institute for "Pulmonary 
Surfactant-Factors Influencing Production."" 

Robert H. Jones, professor in the division of general 
and thoracic surgery, was awarded a $36,894 grant 
from the National Heart, Lung and Blood Institute for 
"Radionuclide Studies in Congenital Heart Disease."" 

Theodore A. Slotkin, professor in the Department 
of Pharmacology, received a $61,388 grant from the 
National Institute of Child Health and Human De- 
velopment of Adrenergic Nervous System."" 

Per-Otto F. Hagen, associate medical research 
professor in the division of general and thoracic 
surgery, received a $141,223 grant from the National 
Heart, Lung and Blood Institute for "Surgical and 
Medical Aspects of Venous Grafts." 

Redford B. Williams Jr.. professor in the division of 
psychosomatic medicine, received a $71,081 grant 
from the National Heart, Lung and Blood Institute for 
the study of "Psychosocial Factors and Outcome in 
Coronary Disease.'" 

Allen D. Roses, professor of neurology and assis- 
tant professor of biochemistry, received an $89,456 



grant from the National Institute of Neurological and 
Communicative Disorders and Stroke for the study of 
"Biochemical Studies of Membrane Proteins in 
Duchenne Muscular Dystrophy."" 

"Roses also received a $25,000 grant from the 
Muscular Dystrophy Association for "Circulating 
Factors in the Pathogenesis of Myasthenia Gravis.'" 



Erdman B. Palmore, professor of community and 
social psychiatry and sociology, received a $72,500 
grant from the National Institute of Mental Health to 
study "Mental Illness and Social Support Among the 
Very Old."" 

Theodore A. Slotkin, professor of pharmacology, 
received a $58,496 grant from the National Institute on 
Drug Abuse for the study of "Effects of Opiates of the 
Adrenergic System."" 

Charles B. Hammond, professor and chairman of 
the Department of Obstetrics and Gynecology, re- 
ceived a $69,721 grant from the National Cancer In- 
stitute for support of the Regional Trophoblastic Dis- 
ease Center. 

David W. Schomberg, associate professor of 
obstetrics and gynecology and physiology, received a 
$94,363 grant from the National Institute of Child 



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584 



Vol. 42, No. 8 



Health and Human Development for the study of 
"Human Infertility: Intraovarian Cellular Mecha- 
nisms." 

Amos Ottolenghi, professor of pharmacology, re- 
ceived a $71,845 grant from the National Institute of 
General Medical Sciences for pharmacological sci- 
ences. 

Wendell F. Rosse, chief of hematology and onocol- 
ogy and professor of microbiology and immunology, 
received a $101,328 grant from the National Heart. 
Lung and Blood Institute for the study of "Blood 
Banking Sciences and Related Areas." Rosse also 
received a $79,245 grant from the National Cancer 
Institute for the study of "Immunological Lysis in 
Neoplastic Disease." 

Andrew G. Wallace, professor of cardiology and 
associate vice president for health affairs, received a 
$258,540 grant from the National Heart. Lung and 
Blood Institute for the study of "Multidisciplinary 
Heart and Vascular Diseases." 



an institution attract and keep quality faculty mem- 
bers." 



The pharmacy residency program at North Carolina 
Memorial Hospital recently received notice of the 
continuation of a six-year accreditation by the Ameri- 
can Society of Hospital Pharmacists. 

The notice was issued by the ASHP Commission on 
Credentialing following review of a pharmacy resi- 
dency progress report submitted by the hospital in 
February 1981. The six-year accreditation is the 
maximum that can be issued by the ASHP. 

The residency program at N.C. Memorial is one of 
about 170 accredited programs in the United States 
and one of two associated with the masters of phar- 
macy practice degree at the University of North Caro- 
lina at Chapel Hill. The School of Pharmacy also has a 
residency program which focuses on pharmacy prac- 
tice at a variety of sites. 



News Notes from the 

UNIVERSITY OF NORTH CAROLINA- 
CHAPEL HILL SCHOOL OF MEDICINE 
AND 
NORTH CAROLINA MEMORIAL HOSPITAL 



The Clinical Research Unit of the School of Medi- 
cine has received a five-year renewal of its operating 
grant from the National Institutes of Health. 

The CRU, located at North Carolina Memorial 
Hospital, is part of a network of federally-supported 
centers for clinical investigation. It is a highly spe- 
cialized unit in which physicians care for patients and 
study their diseases under carefully controlled condi- 
tions. Their research is aimed at discovering the 
causes of complicated disorders and developing better 
ways to treat them. 

The research advisory council of the National In- 
stitutes of Health has recommended that NIH funding 
for CRU increase from $966,000 in 1 982 to $ 1 .3 million 
by 1986. 

The CRU currently has about 70 active research 
projects. 

The unit which includes 14 patient beds, last year 
recorded 855 admissions. The number of outpatient 
visits increased from 334 two years ago to 526 last 
year. 

CRU director Dr. Robert D. Utiger said those num- 
bers reflect an increasing interest among faculty 
physicians in clinical research. 

"We have had more research proposals submitted 
and approved in the last couple of years than ever 
before," Utiger said. "I hope we will continue to have 
a high rate of utilization, because an active research 
program not only advances medical science but helps 

August 1981. NCMJ 



Dr. Stuart Bondurant, dean of the School of Medi- 
cine, is one of nine physicians honored recently with 
mastership in the American College of Physicians 
(ACP). 

As a master of the ACP, Bondurant joins an elite 
group of his medical colleagues. Of the 51 ,000 mem- 
bers of the organization, only 159 hold the rank of 
master. With this honor, Bondurant follows in the 
footsteps of a predecessor as dean of the medical 
school. The late Dr. W. Reece Berryhill. who was 
dean from 1941-64, was named a master of the ACP in 
1977. 

"This is an outstanding professional honor which 
Dr. Bondurant, has received." said University Chan- 
cellor Christopher C. Fordham III. "Traditionally, 
mastership is reserved for physicians who, like Dr. 
Bondurant have consistently upheld the highest stan- 
dards of clinical performance and medical scholarship 
and have contributed other outstanding achievements 
to medical science. 

"By joining this prestigious group. Dean Bondurant 
brings honor not only to himself, but also to the School 
of Medicine and the University." 

Bondurant, immediate past president of the ACP, 
was cited for his accomplishments as a teacher, clini- 
cian and researcher. 

He served on the faculty of Indiana University 
School of Medicine from 1959-67 and Albany Medical 
College from 1967-79. He received several teaching 
awards, including Albany Medical College's Harold 
C. Wiggers Commencement Award. While Bondurant 
was chairman of Albany's Department of Medicine, 
from 1967-74, the number of resident physician po- 
sitions in that department increased from 12 to 70. He 
was named dean and president of Albany Medical 
College in 1974. 

His contributions at Albany also included eight 
years as physician-in-chief of the Albany Medical 
Center Hospital. 



585 



As a researcher in diseases of the heart and lungs, 
Bondurant served as associate director of the Indiana 
University Cardiovascular Research Center from 
1961-67. Near the end of his tenure, he took a leave of 
absence to establish the first program of research on 
myocardial infarction at the National Institutes of 
Health. 

Bondurant's research on the effects of high speed 
acceleration on the heart and lungs contributed sig- 
nificantly to this nation's participation in the space 
age. He received the Air Force Award for Meritorious 
Civilian Service for this work. 

A native of North Carolina and a Phi Beta Kappa 
student at UNC-CH, Bondurant received his medical 
degree from Duke University School of Medicine. He 
returned to Chapel Hill as dean of medicine in 1979. 

The American College of Physicians, founded in 
1915, works to upgrade the quality of medical educa- 
tion, practice and research through rigorous mem- 
bership requirements and continuing medical educa- 
tion programs for physicians. 



Many of the physicians who have been influenced 
by Dr. Floyd W. Denny's 20 years as chairman of 
pediatrics in the School of Medicine recently paid 
tribute to him. 

The first annual Floyd W. Denny Lecture was given 
during the May 22-23 meeting of pediatric alumni and 
friends of the department. This group, formerly 
known as the UNC Pediatric Alumni Society, has 
been renamed the Floyd W. Denny Pediatric Society. 



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"Because Dr. Denny's leadership has had such a 
profound effect on pediatrics across the state and na- 
tion, we felt it was appropriate to rename this organi- 
zation the Denny Pediatric Society and to raise funds 
to endow a continuing lectureship in his honor," said 
Dr. Gerald W. Femald, professor of pediatrics and 
secretary/treasurer of the Denny Society. 

The first Denny lecture was given by Dr. Charles H. 
Rammelkamp, professor of medicine emeritus. Case 
Western Reserve University School of Medicine. 

Denny stepped aside as chairman in May and is 
continuing as Alumni Distinguished Professor of 
pediatrics to pursue his interests in teaching and re- 
search in the division of pediatric infectious diseases. 
Fernald is serving as acting chairman of the depart- 
ment. 



The contributors of five endowed professorships 
were honored April 30 by the School of Medicine. 

Dr. M. D. "Rabbit" Bonner of Greensboro, J. P. 
Riddle of Fayetteville, Dr. and Mrs. Sterling A. Bar- 
rett of Waterloo, Iowa, and Dr. James A. Valone of 
Raleigh were cited for their support of the School of 
Medicine during the spring banquet of the Co- 
Founders Club, a donor organization. Dr. H. Houston 
Merritt, former professor of neurology at Colum- 
bia University, was honored posthumously. 

Earlier in the day, those holding the professor- 
ships spoke during the organization's spring meeting. 
They were: Dr. Thomas P. Bamett, Bonner distin- 
guished professor of pulmonary and allied diseases; 
Dr. W. Paul Biggers, J. P. Riddle distinguished pro- 
fessor of otolaryngology: Dr. David E. Eifrig, the Dr. 
and Mrs. Sterling A. Barrett distinguished professor 
of ophthalmology: Dr. James N. Hayward, the Dr. 
H. Houston Merritt distinguished professor of 
neurology; and Dr. Bradford Cannon, the Dr. James 
A. Valone distinguished professor in plastic and re- 
constructive surgery. 

The day's activities also included the dedication of 
the H. Houston Merritt Electron Microscopy Labo- 
ratory in the UNC-CH Department of Neurology. 

Members of the Co-Founders Club each contribute 
at least $ 1 ,000 a year to the UNC-CH School of Medi- 
cine. The club meets in Chapel Hill each spring and 
fall. 



A physician from North Carolina and another from 
Great Britain will get a firsthand look at each other's 
practice this summer. They will participate in an ex- 
change program sponsored by the Wyeth Labora- 
tories. 

The Area Health Education Centers (AHEC) pro- 
gram of the University of North Carolina at Chapel 
Hill School of Medicine has received a 1981 Wyeth 
Travel Fellowship that will fund a portion of the 
physician's travel and expenses. 

Dr. Eugene S. Mayer, AHEC director, said it will 
enable Dr. Peter Ungaro of Wilmington to spend two 



586 



Vol. 42. No. 8 



weeks in the United Kingdom studying the health care 
delivery system there. Ungaro has a facuhy appoint- 
ment in the School of Medicine through the Wil- 
mington area AHEG. 

The British physician who serves as his host will 
visit North Carolina later in the summer, spending one 
week on campus and one week in the Wilmington 
AHEC region. 

Mayer pointed out that this is the sixth year North 
Carolina's AHEC program has received a Wyeth 
Traveling Fellowship. 

Wyeth Laboratories, a division of American Home 
Products Corp., is a pharmaceutical manufacturer 
with facilities in both the United States and the United 
Kingdom. 



Scientists at the University of North Carolina at 
Chapel Hill have developed a group of compounds 
that appear to be effective in controlling respiratory 
syncytial virus — the leading cause of respiratory 
infections among American children. 

It's not known yet if the synthetic compounds, 
called amidines, will work as well in humans as they 
do in the test tube, but preliminary studies in animals 
are encouraging, the scientists said. 

If the amidines make it through years of further 
animal testing and clinical trails, they could eventually 
become a significant new anti-virus tool for physi- 
cians. A patent on three of the compounds is expected 
to be granted later this year. 

Although respiratory syncytial virus (RSV) can af- 
fect persons of any age. causing symptoms that range 
fi"om runny noses to bronchiolitis and pneumonia, it is 
particularly dangerous for children under age 2 and the 
elderly. Dr. Richard R. Tidwell, assistant professor of 
pathology at the UNC-CH School of Medicine, said 
! that in some cases, the inflammation it produces in the 
lungs becomes severe enough to require hospitaliza- 
tion and breathing devices. 

He said he and his colleagues, Drs. Edward J. 
Dubovi, assistant professor of pediatrics, and Joachim 
D. Geratz, professor of pathology, have been using 
certain amidines to interfere with functions of the 
virus. They can't simply kill the infectious agents be- 
cause drugs strong enough to do that are invariably 
harmful to the cells they are supposed to protect. 

Reports on the UNC-CH scientists' research, 
which is supported by the National Institutes of 
Health, appeared in the April issue of the journal 
Antimicrobial Agents and Chemotherapy and the 
June 1980 issue of Virology. 



Dr. Edward J. Shahady has been reappointed 
chairman of the Family Medicine Department. The 
five-year appointment was effective Jan. 1 . 

Before joining the faculty in 1976. Shahady was 
director of the family practice resident program at 
Akron, Ohio, City Hospital and chairman of the De- 



t 



partment of Family Practice at Northeastern Ohio 
University's College of Medicine. 

The Fairmont, W.Va. native received the Thomas 
W. Johnson Award for outstanding contributions to 
family practice education in 1979. Shahady is presi- 
dent of the Society of Teachers of Family Medicine. 
He is a charter fellow of the American Academy of 
Family Physicians and a charter diplomate of the 
American Board of Family Medicine. 

A graduate of Wheeling College in West Virginia, he 
earned his M.D. degree from West Virginia University 
in 1964. 



Dr. Frank C. Wilson Jr., professor and chief, divi- 
sion of orthopedic surgery, was appointed to the Resi- 
dency Review Committee for Orthopaedics. 



Dr. Jeffry J. Andresen. associate professor of psy- 
chiatry, spoke on psychoanalysis in psychiatric edu- 
cation at the Michael Reese Hospital and Medical 
Center conference in March 6-7 in Chicago. 



Maryls Mitchell, associate professor and director of 
occupational therapy, participated in the American 
Occupational Therapy Association annual conference 



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by chairing a session and a committee, serving as 
academic representative to the education commission 
and participating in executive board meetings March 
3-13 in San Antonio, Texas. 



Dr. Robert A. Briggaman, professor of dermatol- 
ogy, and Dr. W. Ray Gammon, assistant professor of 
dermatology, lectured at the 1981 Internal Medicine 
Program. Briggaman spoke on "Drug Induced Dis- 
eases" and Gammon spoke on "Vasculitis" March 1 1 
in Chapel Hill. 



Dr. Edward J. Shahady. chairman of family medi- 
cine, was guest faculty member at the Caribbean 
Conference on Diagnostic Medicine held in San Juan, 
Puerto Rico. He delivered papers on "Routine Pre- 
natal Care" and "Pediatric Care" on March 14 and 15. 



Michael R. McGinnis, assistant professor of bac- 
teriology and immunology, wrote a book titled "Lab- 
oratory Handbook of Medical Mycology" published 
by Academic Press of New York. 



James Lea, associate professor and director of the 
Program for International Training in Health, and 
Rosalia Rodriguez, training director, participated in 
the INTRAH Communications Workshop Feb. 9 in 
Rabat, Morocco. 



Richard V. Wolfenden, professor of biochemistry, 
presented a lecture and participated in the organiza- 
tion of the 26th OHOLO Biological Conference on 
synthetic enzymes and transition state analogs March 
22-25 in Zichron Yaakov, Israel. 



Six faculty members from the School of Medicine 
have been promoted to associate professor effective 
July 1 . They include: Roy C. Orlando, John F. Rogers, 
James R. Foster, Department of Medicine; Paul F. 
Jaques, Department of Radiology; Timothy N. Taft, 
Department of Surgery; and James D. Thullen, De- 
partment of Pediatrics. 



Dr. Walter B. Greene, assistant professor of sur- 
gery, presented a paper titled "A Comparative Study 
of Bilateral Versus Unilateral Congenital Dislocation 
of the Hip" to the annual meeting of the American 
Academy of Orthopaedic Surgeons, Feb. 28 in Las 
Vegas, Nev. He also presented a poster exhibit by the 
same title at the meeting. 



Ronald G. Thurman, associate professor of phar- 
macology, presented two papers as the Smith, Kline 



588 



and French visiting professor of pharmacology March 
9-10 at the University of Pittsburgh. 



Joan C. Rogers, assistant professor of allied health 
professions, was named a fellow of the American Oc- 
cupational Therapy Association March 10 in San An- 
tonio, Texas. 



Dr. Edward V. Stabb, professor and associate 
chairman of radiology, was visiting professor of the 
Department of Radiology at the University of South 
Carolina, Columbia, S.C., March 9-13. 



Dr. Herbert J. Proctor, associate professor surgery, 
participated in a meeting of the Mississippi Surgical 
Forum VIII postgraduate course, "Update on Man- 
agement of Fluid, Electrolyte and Acid Base Problems 
in Surgery," March 13 in Jackson, Miss. He also 
moderated another session titled "Shock." 

Proctor spoke on "Vascular Trauma" at the annual 
refresher course of the American Society of Abdomi- 
nal Surgeons, March 22, at the Study Center in 
Tampa. 



Dr. James R. Dingfelder, associate professor of 
obstetrics and gynecology, and Dr. Gary S. Berger, 
assistant professor of obstetrics and gynecology, pre- 
sented papers at the 11th annual conference of the 
Nurses Association of the American College of Ob- 
stetricians and Gynecologists on March 14 in Raleigh. 



Dr. Colin D. Hall, associate professor of neurology, 
and Dr. James F. Howard, assistant professor of 
neurology, were co-chairmen of the Symposium of the 
Eastern Regional Clinic Directors of the Muscular 
Dystrophy Association on March 14-15 in Chapel Hill. 
Dr. Walter B. Greene, assistant professor of surgery 
participated as a speaker. 



Dr. Arthur J. Prange Jr., professor of psychiatry, 
conducted grand rounds at Albert Einstein Medical 
College, The Beth Israel Medical Center, and St. 
Luke's-Roosevelt Medical Center March 16-18. 
Prange lectured on the Therapeutic Aspect of Psycho- 
endocrinology. 



Dr. Steven Pierson, surgery resident, Denise Pier- 
son, nursing, and Dr. George Johnson Jr., professor 
and chairman of surgery, co-authored a paper titled 
"Elastic Compression for Control of Leg Swelling." 
The paper was presented at the third European- 
American Symposium on Venous Diseases, March 
19-24 in Acapulco. Prior to the symposium, Johnson 
served on the Scientific Program Committee and 

Vol. 42, No. 8 



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coordinated the session on Operative Management of 
Portal Hypertension. 

Johnson was a visiting professor at the University of 
Texas Health Science Center. He presented a talk 
titled "Review of Management of Portal Hyperten- 
sion and Bleeding Esophageal Varices" March 29-30 
in San Antonio. 



Kenneth C. Mills, associate professor, center for 
alcohol studies, gave a training workshop on college 



alcohol programs on March 26 at the Johns Hopkins 
Third Annual Conference in Baltimore, Md. 



William G. Thomas, associate professor of surgery, 
was awarded honors by the North Carolina Speech- 
Hearing-Language Association in appreciation of his 
contributions in audiology at the NCSHLA annual 
meeting March 26-28 in Asheville. He lectured on 
"Use of Auditory Brain-stem Response in Threshold 
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August 1981, NCMJ 



591 



Dr. Philip Sloane and Dr. Peter Curtis, assistant 
professors of family medicine, and Bron Skinner, 
educational specialist, family medicine, presented a 
paper at the North American Primary Care Research 
Group Conference held in March at Lake Tahoe. Nev. 



Dr. Janet J. Fischer, professor of medicine, pre- 
sented a scientific paper titled "Microbiological 
Studies of Cotton — A Review" at the American 
Chemical Society meeting in Atlanta, March 29- 
April 3. 



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Dr. Robert A. Briggaman, professor of dermatol- 
ogy, attended the annual workshop on Disease Mech- 
anisms in Epidermolysis Bullosa, April 2-3, in Be- 
thesda, Md. He presided over one of the program 
sections and gave a lecture on "Anchoring Fibrils — 
Recombinant Graft Studies." 



Dr. W. Ray Gammon, assistant professor of der- 
matology, attended the Second Annual Physician As- 
sistant Refresher Course April 7, at Fort Bragg. He 
lectured on "Open and Closed Wet Dressings for the 
Treatment of Acute Skin Disease," "Dry Skin and 
Eczemas," "Meningococcemia" and "Vasculitis." 



Dr. Donald C. Whitenack, associate professor of 
family medicine, was course director for the North 
Carolina Chapter of the American Academy of Family 
Medicine's 1981 "What's New in Family Medicine" 
program, June 29-July 3, at Appalachian State Uni- 
versity in Boone. 



News Notes from the — 

EAST CAROLINA UNIVERSITY 
SCHOOL OF MEDICINE 



East Carolina University awarded medical degrees 
to its first class of physicians in a May 8 ceremony that 
was characterized by Gov. James B. Hunt Jr. as a 
milestone and the realization of a dream come true for 
many people. 

Hunt joined with ECU Chancellor Emeritus Leo W. 
Jenkins in placing doctoral hoods on the 28 students in 
a colorful ceremony frequently marked by applause 
for the young physicians and the development of the 
School of Medicine. Chancellor Thomas B. Brewer 
presented diplomas to the class. 

Students, their families and supporters of the school 
were also honored at a School of Medicine convoca- 
tion May 7. Speakers included Dean William E. 
Laupus, Chancellor Brewer, Judge H. Horton Roun- 
tree, Dr. Edwin W. Monroe, Dr. Wallace R. Wooles 

Vol. 42, No. 8 



and Dr. Harold C. Wiggers. Jenkins was the keynote 
speaker. 

Highlighting the convocation was the presentation 
of student awards. Eugene Davis Day Jr. of Durham 
received the Edgar T. Beddingfield Jr. Memorial 
Award honoring the late Dr. Beddingfield of Wilson, 
the Jacob Furth Memorial Award in internal medicine , 
the Department of Pathology Award and the William 
E. Laupus Pediatrics Award. Linda Robertson of 
Rural Hall received the Sandoz Pharmaceutical 
Award, the John Hunter Award in surgery and the 
American Medical Women's Association Award. 

Other awards included the Department of Anatomy 
Award and Department of Pathology Award to 
Thomas L. Beatty Jr. of Charlotte; the Family Prac- 
tice Award to Michael David Tripp of Ash; the De- 
partment of Pathology Award to Kenneth Stuart Lee 
of Smithfield; the Philip G. Nelson Award in psychia- 
try to Bonnie A. Caulkins of Murfreesboro; the De- 
partment of Radiology Award to Tony P. Smith of 
Conover; and American Medical Women's Associa- 
tion Awards to Bonnie Caulkins and Mary Beth Foil of 
Chapel Hill. 

David R. Faber of Charlotte, president of the Class 
of 1981, presented faculty awards for outstanding 
teaching. They included the Resident Award to Dr. 



David Pearsall, the Basic Science Award to Dr. 
Hubert Burden, the Clinical Faculty Award to Dr. 
W. Ray Walker and the Community Physician Award 
to Dr. Jack Welch. Students also recognized Dr. 
Seymour Bakerman, chairman of the Department of 
Pathology, by naming the class scholarship fund in his 
honor. 

In July the charter class of physicians began resi- 
dency training at 16 medical centers across the coun- 
try. Eleven of them remained in North Carolina, five 
at ECU and Pitt County Memorial Hospital. Twelve of 
the students selected residencies in family medicine, 
four in obstetrics and gynecology, two in pediatrics, 
two in surgery, two in psychiatry and one each in 
radiology, anesthesiology, neurology, internal medi- 
cine and otorhinolaryngology. One student has not 
designated a specialty. 



The ECU School of Medicine has been awarded 
full, four-year accreditation from the Liaison Com- 
mittee on Medical Education. The accrediting agency 
also granted the school permission to increase 
freshman enrollment to 52 students in the fall of 1981 . 

ECU received provisional accreditation for the 
four-year program in April 1977 and admitted the 



August 1981, NCMJ 



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charter class in August that year. LCME representa- 
tives last visited the school in November 1980 to ex- 
amine the progress of the program before the gradua- 
tion of the first physicians. 

The increase in freshman admissions will raise the 
enrollment to 174 students next year. 



medical education and evaluation. Dr. Robert P. Dil- 
lard, assistant professor of pediatrics, and Dr. Angela 
Stewart, resident in pediatrics, have received $2,500 
from Ross Laboratories to study "The Present Prac- 
tice of Pediatricians in Providing Newborn Health 
Care Information to Parents." 



Dr. John Moskop, assistant professor of pediatrics 
and humanities, presented "The Role of the M.D. and 
the Patient's Right to Choose Suicide" to faculty and 
students at State University Hospital of the Upstate 
Medical Center, Syracuse, N.Y. 

An article by Moskop and Dr. Loretta Kopelman, 
associate professor of pediatrics and humanities, ap- 
pears in the May issue of Ihe Journal of Medicine and 
Philosophy. The article is entitled "The Holistic 
Health Movement: A Survey of Critique." 



Two members of the Department of Physiology 
have received recognition awards from the American 
Heart Association. Dr. Edward M. Lieberman. pro- 
fessor, received the Founder's Award, and Dr. John 
C. Yeager, assistant professor, received the 
Achievement Award. 



Dr. Robert S. Fulghum, associate professor of mi- 
crobiology, gave the Louis B. Smith Honorary Lec- 
ture May 15 at Christopher Newport College in New- 
port News, Va. His lecture was entitled "The Role of 
Anaerobic Bacteria in Selected Environments In- 
cluding Their Role in Infections." 



Dr. E. Jackson Allison Jr., associate professor and 
chairman of the Department of Emergency Medicine, 
was a seminar leader at the state conference of the 
Association of Emergency Medical Technicians and 
the Emergency Department Nurses Association. The 
seminars were entitled "From the Ditch to I.C.U.: 
Code Blue and Crash Carts" and "What E.M.S. Is All 
About." 

Allison also has been appointed chairman-elect of 
the Section on Emergency Medicine of the N.C. 
Medical Society. 



Dr. P. Bruce Campbell, associate professor of 
medicine, and Dr. Yash P. Kataria, associate profes- 
sor of medicine are the authors of "Sarcoidosis: Elab- 
oration of an Inhibitor of Monocyte Leukotaxis 
(MLX) by Cutaneous Granulomata (SCO)." 
Campbell presented the paper in San Francisco to the 
American Federation for Clinical Research. 

Campbell also presented "Sarcoidosis: Leukotactic 
Lymphokine Production by Intact Cutaneous 
Granulomata" at the American Lung Association's 
annual meeting in Detroit. Kataria was also coauthor. 

Kataria, Campbell and Dr. Byron T. Burlingham, 
professor and chairman of the Department of Micro- 
biology, published "Acute Pulmonary Histoplas- 
mosis Presenting as Adult Respiratory Distress Syn- 
drome: Effective Therapy on Clinical and Laboratory 
Features" in the May issue of the Southern Medical 
Journal. 



Several members of the Department of Biochemis- 
try attended the American Society of Biological 
Chemists meeting in St. Louis May 31 -June 4. Repre- 
senting the department were Dr. Wilhelm R. Frisell, 
professor and chairman. Dr. Sam N. Pennington, 
professor, and Dr. Richard H. L. Marks, associate 
professor. Pennington presented "Ethanol-Induced 
Suppression of Fetal Growth." and Marks presented 
"Chemical Crosslinking of Azurin and Cytochrome 
c-551 from Pseudomonas Aeruginosa." 



Dr. Uwe R. Muller, assistant professor of micro- 
biology, has received $19,000 from the N.C. Board of 
Science and Technology to study the "Construction 
of 0X174, G4, and SV40 Mutants with Modified In- 
tercistronic Regions." 



Dr. Frank Thomas, professor of surgery, presented 
"Multi-Organ Donation" at the Fourth Annual Ne- 
phrology Symposium in Omaha, Neb. 



Dr. James Mathis, professor and chairman of the 
Department of Psychiatry, attended the Oklahoma 
State Medical Association's meeting and presented 
"Suicide: The Mortality of Depression," "Psychiatry 
in Medicine" and "Cults." 



Dr. Melvin S. Swanson, associate director for 



Dr. R. Stephen Porter, assistant professor family 
medicine, presented "General Principles of 
Therapeutic Drug Monitoring" to the Department of 
Medicine at Memorial Hospital in Danville, Va., on 

May 5. 



Dr. G. Lynis Dohm, associate professor of 
biochemistry, presented "Increased Excretion of 
N'^'-Methylhistidine and Urea by Rats and Humans 
After a Bout of Exercise" to the American College of 
Sports Medicine meeting in Miami Beach May 26-29. 



594 



Vol. 42, No. 8 



The Center for Student Opportunities recently 
sponsored its Third Annual Health Careers Day. More 
than 100 students from N.C. and Virginia high schools 
and colleges attended the one-day program conducted 
by directors and associate directors from the N.C. 
Health Manpower Development Program. 

NORTH CAROLINA HOSPITAL ASSOCIATION 

Dr. Christopher Fordham. chancellor of the Uni- 
versity of North Carolina at Chapel Hill, was pre- 
sented the N.C. Hospital Association Distinguished 
Service Award at a ceremony in May on the campus. 
The award, the highest bestowed by the association. 



was presented by Donald C. Hiscott, chairman of the 
association trustees. 



AMERICAN COLLEGE OF CARDIOLOGY 

Eric H. Conn, M.D., of the Duke University Medi- 
cal Center is one of five recipients of $15,000 Adult 
Cardiology Fellowship Training Awards under a new 
program established by the American College of Car- 
diology and the Merck Company Foundation. The 
one-year awards support the development of new pro- 
grams in clinical and preventive medicine which may 
have a positive impact on the high mortality and mor- 
bidity statistics for cardiovascular disease. 



The mind may be considered as the granary, into which the senses, as the labourers, collect 
knowledge for future purposes. The wider the range of the power of the latter, the greater will 
be the harvest gathered by them. Thus the telescope by enlarging the sphere of vision, has 
discovered new phenomena in the heavens: and the tests of chemistry are assistant agents in 
rendering sensible qualities which would otherwise have passed unobserved on the earth. 
The microscope may probably be employed to discover properties now unknown, and 
introduce us to a world of objects near to us, as vast and as curious for its minuteness, as that 
of the great and distant objects, which the telescope has demonstrated. 

It is thus, then, by increasing the power of the senses, that science becomes more 
productive. When, however, we look around us. and find that all nature, instead of being at 
rest, presents a scene of constant motion and change, connected and hung together in a series 
of indissoluble links, we are led to examine other relations of bodies: relations which 
constitute the most essential parts of all knowledge — those of cause and effect. In medicine, 
their history is that of the origin and the cure of diseases: it therefore deserves minute and 
accurate investigation. Let us examine a few instances. Arrest the supply of oxygen to the 
lungs, and life ceases in the more perfect animals. Continued frost stops the fevers of 
summer. Emetics produce a discharge of the contents of the stomach. In all these instances, 
the effect is invariably and indissolubly connected with its cause. They have continued the 
same from the earliest observation, and will do so to the end of time. Cause and effect are, 
therefore, the most important considerations of medical and other sciences. — Elements of 
the Theory and Practice of Physic, by George Gregory, M.D., with notes and additions, 
adapted to the Practice of the United States, by Nathaniel Potter, M.D., and S. Colhoun, 
M.D. Vol. I, Philadelphia, Towar & Hogan, 1829. 



August 1981, NCMJ 



595 




JOHN COCHRANE REECE, M.D. 

Dr. John Cochrane Reece, for many years director 
of the Laboratory and Pathology Departments of 
Grace Hospital in Morganton, died Jan. 1 1 . During the 
time that he was the only pathologist between Ashe- 
ville and Winston-Salem, he offered his services to 
hospitals in a number of surrounding communities and 
was still serving some of the smaller hospitals at the 
time of his death. Dr. Reece went from Statesville 
High School to Mars Hill Junior College, then to Wake 
Forest College at Wake Forest, graduating with a B.S. 
degree in 1936. While at Wake Forest he worked in the 
laboratories to help pay for his medical education, and 
his pathology professor. Dr. Coy C. Carpenter, who 
later became dean of the Bowman Gray School of 
Medicine, encouraged him to become a pathologist. 

On the recommendation of Dr. Thurmond Kitchen, 
Dr. Reece, when he had completed Wake Forest's 
two-year medical program, went to the New York 
University Medical School, where he graduated in the 
top level of his class. He received his North Carolina 
license to practice medicine in 1938 and after a year's 
internship in pathology at Saint Vincent's Hospital in 
New York, he returned for his residency in pathology 
at N.C. Baptist Hospital ( 1 938-4 1 ), serving at the same 
time as instructor in pathology for the Bowman Gray 
School of Medicine which was being established in 
Winston-Salem. 

Dr. Reece served in the Medical Corps from 1942 
through 1946, holding assignment at the Army Insti- 
tute of Pathology in Washington, and later working 
with the 154th General Hospital in Bournemouth, En- 
gland. He obtained the rank of major. 

He began an active medical career in Morganton 
and Burke county in 1946. Establishing a pathology 
department in the area was a new experience for both 
the professional people and the citizens. The word 
"autopsy" had to be carefully explained, and Dr. 
Reece was the one who could, in his compassionate 
manner, deal with each case not as a number but 
as an individual person. His careful explanations 
to families, to fellow doctors, to lawyers, to the 
courts, to the news media, were compassionate, fac- 
tual and well documented. 

His professional associations and honors were 
many. In 1958 he was elected coroner of Burke 



county, having been available for the previous 12 
years to conduct autopsies at the request of the local 
coroner and for mysterious deaths throughout the 
area. He worked to get the medical examiner system 
established in North Carolina, and the archaic coroner 
system was dissolved in Burke county during his ad- 
ministration and he became medical examiner and 
regional pathologist. 

Dr. Reece was a member of the Burke County 
Medical Society, serving as president in 1958, presi- 
dent of Grace Hospital Medical staff in 1952 and 1967, 
a member of the American Medical Association and 
the North Carolina Society of Pathologists (president 
1955-56), and a Fellow of the American Society of 
Clinical Pathologists. Always interested in organized 
medicine to promote medicine to the highest levels, he 
became active in the North Carolina Medical Society 
and began a number of years of service to this organi- 
zation. He was Ninth District Councillor, a member of 
the Executive Council, president-elect of the society 
and then president in 1959-60. At 44, he was the sec- 
ond youngest president ever elected and the second 
Burke county physician to head the society since 
1900. Dr. Reece headed the society's grievance com- 
mittee in 1961-62 and was speaker of the House of 
Delegates from 1962-65. He served as chairman of 
Eastern Appalachian Regional Health Council and in 
Burke county was active in the Council on Al- 
coholism, attending physician at the Red Cross 
Bloodmobile for \1V2 years, a favorite organization of 
his, and a member and medical advisor of the rescue 
squad. He was appointed chairman of Hospital Board 
of Control by Gov. Luther Hodges; a member of the 
Medical Advisory Council of the State Board of Men- 
tal Health by Gov. Terry Sanford and by Gov. Robert 
Scott: and, to the North Carolina Cancer Study Com- 
mission by Gov. Dan K. Moore. 

Dr. Reece was co-author of a paper on "Simultane- 
ous Death in Schizophrenic Twins" — the unusual 
deaths occurred at Broughton Hospital. He was a 
member of the Burke County Historical Society and a 
deacon and elder of First Presbyterian Church. 

He is survived by his wife, Adelaide, and three 
children, Mrs. James Small of Birmingham, Ala., Mr. 
Robert Reece of Raleigh, and Mr. John C. Reece, Jr., 
of Morganton. 

Burke County Medical Society 



5% 



Vol. 42, No. 8* 



Committee & 

Commission Appointments 

1981-1982 



lUGUST 1981. NCMJ ~ 597 



Committee and Commission Appointments 

1981-1982 

NOTE: The committees listed herein have been authorized by President Josephine E. Newell, M.D.. and/or as required under 
the Constitution and Bylaws. Particular note should be taken of the authorization of the HOUSE OF DELEGATES of 
aCommissionformoforganizationactivity and that all Committees, excepting COMMITTEE ON NOMINATIONS, 
COUNCIL ON REVIEW AND DEVELOPMENT, and MEDIATION COMMITTEE are segregated under the 
respective Commission in which the function of the Committee logically rests. This will tend to eliminate overlapping 
and duplication in activity programs and result in coordination of the work of the Society in a manner to lessen the 
work of the Delegates in the Annual Meeting of the HOUSE OF DELEGATES. 

(Superior figures ie.g. 21) mdicale the iumponent County Society from which the member emanates, as in the Membership list of the ROSTER.) 



I. ADMINISTRATION COMMISSION 

Thomas B. Dameron. Jr.. M.D.. Commis.sioncr (919-781-5600) 
P.O. Box 10707. Raleigh 27605 

Committee 
Listing 

1. Finance Com. on (I-l) No. 17 

Ernest B. Spangler. M.D.. Chairman (919-855-8972) 
Drawer X-3, Greensboro 27402 

2. Insurance Plans, Com. to Investigate Various (1-2) No. 22 
Jesse Caldwell, Jr., M.D., Chairman (704-865-0968) 

1307 Park Lane. Gastonia 28052 

3. Membership, Com. on (1-3) No. 33 
John W. Foust. M.D., Chairman 

3535 Randolph Rd.. Charlotte 28211 (704-365-0711) 

4. Personnel & Headquarters Operation, Com. on (1-4) No. 38 

Shahane R. Taylor. Jr.. M.D.. Cliairman (919-274-4262) 
348 N. Elm St.. Greensboro 27401 

5. Professional Insurance, Com. on (1-5) No. 41 
Julius A. Green. Jr.. M.D., Chairman (919-787-8221) 

P.O. Box 19366. Raleigh 27609 

6. Retirement Savings Plan Committee (1-6) No. 43 

W. Lester Brooks. Jr.. M.D.. Chairman (704-333-4175) 
1851 E. Third St.. Charlotte 28204 

7. ad hoc Com. to Delineate the Administrative Code No. 46 

for the North Carolina Medical Society (1-7) 

E. Thomas Marshburn. Jr., M.D., Chairman (919-762-9621) 

3208 Oleander Dr.. Wilmington 28401 

II. ADVISORY AND STUDY COMMISSION 

F. Maxton Mauney. Jr. . M.D.. Commissioner (704-258-1 121) 
257 McDowell St.. Asheville 28803 

Committee 
Listing 

1. Allied Health Professionals, Com. on (II- 1) No. 2 
Thad B. Wester. M.D.. Chairman (919-739-3318) 

103 W. 27th St.. Lumberton 28358 

2. Cancer, Com. on (11-2) No. 6 
Charles L. Spurr. M.D.. Chairman (919-748-4464) 
Bowman Gray. Winston-Salem 27103 

3. Medical Cost Containment, Com. on (II-3) No. 29 

Jack B. Hobson. Wl.D.. Cliairman (704-374-1296) 
1351 Durwood Dr.. Charlotte 28204 



598 



4. Medicine & Nursing, Com. on Relationships No. 32 

between (II-4) 

C. Glenn Pickard. Jr., M.D., Chairman (919-966-5650) 
N.C. Memorial Hospital. Chapel Hill 27514 



i 



5. Operative Deaths, Com. on Study of (II-5) No. 37 

Albert A. Bechtoldt. Jr., M.D.. Chairman (919-966-5136) 
UNC. Dept. of Anes., Chapel Hill 27514 

6. Traffic Safety, Com. on (II-7) No. 45 
George Johnson. Jr.. M.D.. Chairman (919-966-3391) 

N.C. Memorial Hospital. Chapel Hill 27514 



III. ANNUAL CONVENTION COMMISSION 

Gloria F. Graham, M.D., Commissioner (919-291-56001 
702 Broad St., Wilson 27893 

Committee 
Listing 

1. Aging, Com. on (III-l) No. 1 

Edna M. Hoffman, M.D.. Chairman (919-485-8801) 
348 Valley Rd.. Fayetteville 28305 

2. Arrangements, Com. on (III-2) No. 3 f 

Jack Hughes. M.D., Cliairman (919-286-1297) ; 

923 Broad St., Durham 27705 

3. Auxiliary, Com. Advisory to (II1-3) No. 4 

Rose Pully. M.D., Chairman (919-523-2569) 
318 College St.. Kinston 28501 

5 

4. Constitution & Bylaws, Com. on (III-4) No. 9 

P. G. Fox, Jr., M.D.. Chairman (919-876-4323) 
P.O. Box 17908. Raleigh 27619 

5. Credentials, Com. on (of Delegates to House of No. 11 

Delegates) (1II-5) 

Louis R. Will^erson. M.D., Chairman (919-832-5529) 
100 S. Boylan Ave.. Raleigh 27603 

6. Ethics & Religion, Com. on (III-6) No. 15 

Gloria F. Graham, M.D., Chairman (919-291-5600) 
702 Broad St.. Wilson 27893 



1 



7. Medical Education, Com. on (III-7) No. 30 

John D. Bridgers. Sr., U.D.. Chairman (919-882-4171) 
624 Quaker Lane. Ste. 200-A, High Point 27262 

Vol. 42, No. 8 



IV. PROFESSIONAL SERVICE COMMISSION 

Charles A. Hoffman. Jr.. M.D.. Commissioner (919-485-8801) 
513 Owen Dr.. Fayetteville 28304 



VI. PUBLIC SERVICE COMMISSION 

Rose Pully. M.D.. Commissioner. (919-523-2569) 
318 College St.. Kinston 28501 



Committee 
Listing 
1. Blue Shield. Com. on (IV-1) No. 5 

Walter M. Roufail. M.D.. Chairman (919-725-8326) 
2240 Cloverdale Ave.. Ste. 88. Winston-Salem 27103 



Committee 
Listing 
1. Child Health & Infectious Diseases, Com. on (VI-1) No. 7 

William L. London. M.D.. Cluiirman (919-688-6349) 
306 S. Gregson St.. Durham 27701 



2. Crippled Children's Program, Com. Adv. to (IV-2) 
David R. Williams. M.D.. Cluiirman (919-475-2348) 
Southgate Shopping Center. Thomasville 27360 

3. Health Planning & Development, Com. on (IV-3) 
William E. Laupus. M.D.. Chairman (919-757-4627) 
ECU. Dean's Office. Greenville 27834 



No. 12 



No. 19 



No. 20 



4. Human Resources, Com. Liaison to Dept. of (IV-4) 

Julian F. Keith. Jr.. M.D.. Chairman (919-748-2251) 
Bowman Gray. Dept. of Family Med.. Winston-Salem 27103 

5. Industrial Commission, Com. to Work with No. 21 

N.C. (IV-5) 
Thomas E. Castelloe. M.D.. Chairman (919-781-5600) 
P.O. Box 10707. Raleigh 27605 

6. Rehabilitation Medicine, Com. on (IV-6) No. 42 

Robert E. Miller. M.D.. Chairman (704-373-0544) 
1822 Brunswick Ave.. Charlotte 28207 

7. Social Services Programs, Com. on (Including No. 44 

Medicaid) (IV-7) 
Joseph D. Russell. M.D., Chairman (919-291-1300) 
Carolina Clinic, Wilson 27893 



V. PUBLIC AFFAIRS COMMISSION 

John L. McCain, M.D.. Commissioner (919-291-7001) 
Wilson Clinic. Wilson 27893 

Committee 
Listing 
Communications, Com. on (V-1) No. 8 

Elizabeth P. Kanof. M.D.. Chairman (919-833-3672) 
1300 St. Mary's St.. Raleigh 27605 



2. Disaster & Emergency Medical Care, Com. on (V-2) 
Joseph A. Moylan. M.D.. Chairman (919-684-2237) 
Duke Med. Ctr.. Box 3056. Durham 27710 



No. 13 



3. Eye Care & Eye Bank, Com. on (V-3) No. 

Albin W. Johnson. M.D.. Chairman (919-781-7400) 
2800 Blue Ridge Blvd.. Ste. 409. Raleigh 27607 



16 



4. Legislation, Com. on (V-4) 

Don C. Chaplin. M.D.. Chairman (919-227-3621) 
Kernodle Clinic. Burlington 27215 



No. 24 



5. Medical Aspects of Sports, Com. on (V-5) No. 27 

Frank W. Clippinger. Jr.. M.D.. Chairman (919-684-4229) 
Duke Med. Ctr.. Box 3935. Durham 27710 



6. Medical-Legal Committee (V-6) 

Julius Howell. M.D.. Chairman (919-748-4171) 
Bowman Gray. Winston-Salem 27103 

August 1981. NCMJ 



2. Drug Abuse & Pharmacy, Com. on (VI-2) No. 14 
John A. Ewing. M.D.. Chairman (919-966-4551) 

N.C. Memorial Hospital. Chapel Hill 27514 

3. Jail Project, Com. Advisory to (VI-3) No. 23 
Philip G. Nelson. M.D.. Chairman (919-758-3145) 
Medical Pavilion. Ste. 9. Greenville 27834 

4. Maternal Health, Com. on (VI-4) No. 25 
Robert G. Brame. M.D.. Chairman (919-757-4620) 

ECU. Dept. of OB-GYN. Greenville 27834 

5. Mental Health. Com. on (VI-S) No. 34 
Wilmer C. Betts. M.D.. Chairman (919-782-0166) 

3125 Glenwood Prof. Village. Raleigh 27608 

6. Occupational & Environmental Health, Com. (VI-6) No. 36 
Austin T. Hyde. Jr.. M.D.. Chairman (704-286-9036) 

P.O. Box 970. Rutherfordton 28139 

7. Physicians' Health & Effectiveness, Com. on (VI-7) No. 39 
Theodore R. Clark. M.D.. Chairman (919-295-1231) 

P.O. Box 1569. Pinehurst 28374 

8. Medical Care of Prison Residents, Com. to No. 48 

Investigate Grievances Relative to (VI-8) 
Jesse Caldwell. Jr.. M.D.. Chairman (704-865-0968) 
1307 Park Lane. Gastonia 28052 



COMMITTEES NOT ASSIGNED TO A COMMISSION 
COUNCIL ON REVIEW & DEVELOPMENT 

J. B. Warren. M.D.. Chairman (919-637-6193) 
P.O. Box 1465. New Bern 28560 

MEDIATION COMMITTEE 

Jesse Caldwell. Jr.. M.D.. Chairman (704-865-0968) 
1307 Park Lane. Gastonia 28052 
Frank Sohmer. M.D.. Secretary (919-725-8326) 
2240 Cloverdale Ave.. Ste. 88. Winston-Salem 27103 

COMMITTEE ON NOMINATIONS 

Gloria F. Graham. M.D.. Chairman (919-291-5600) 
702 Broad St.. Wilson 27893 

1. Committee on Aging III-l (7) (2 Consultants) 

Edna M. Hoffman. M.D.-" Cluiirman (919-485-8801) 

348 Valley Rd.. Fayetteville 28305 
Paul Beck. M.D.»- (IM) (919-755-8532) 

3000 New Bern Ave.. Raleigh 27610 
Donald V. Chamblee. M.D.«" (GP) (704-366-5002) 

P.O. Box 220892. Charlotte 28222 
Joseph J. Combs. M.D.''- (IM) (919-787-9032) 

2125 White Oak Rd.. Raleigh 27608 
James S. Forrester. M.D." (FP) (704-263-4716) 

P.O. Box 459. Stanley 28164 
Frank W. Leak. M.D."- (FP) (919-592-6011) 
No. 31 Clinton Med. Ctr.. Clinton 28328 

John L. McCain. M.D.''" (RHU) (919-291-7001) 

Wilson Clinic. Wilson 27893 



599 



Consultants: 

Mrs. Hampton Hubbard (Anne) 

(Auxiliary President) (919-592-7885) 

102 Country Club Circle. Clinton 28328 
Mrs. Edwin Martinat (Martha) (Auxiliary) (919-678-0339) 

120 Sherwood Forest Rd., Winston-Salem 27104 



2. Committee on Allied Health Professionals ll-l (8) (5 Consultants) 

Thad B. Wester. M.D.'" (PD) Chairman (919-739-3318) 

103 W. 27th St.. Lumberton 28358 
Roy A. Agner. Jr., M.D."" (IM) (704-633-7220) 

611 Mocksville Ave.. Salisbury 28144 
William M. Fowlkes. Jr.. M.D."- (P) (919-851-8888) 

1209 Glendale Dr.. Raleigh 27612 
Susan S. Gustke. M.D.''= (IM) (919-733-5431) 

4100 Stranaver PI.. Raleigh 27612 
Ira M. Hardy. II. M.D.'^ (NS) (919-752-5156) 

125 Moye Blvd.. Greenville 27834 
Henry H. Nicholson, Jr.. M.D."" (GS) (704-375-8956) 

1012 Kings Dr.. Ste. 708, Charlotte 28283 
Frank N. Sullivan, M.D."» (FP) (919-243-3395) 

603 E. Nash St., Wilson 27893 
Wayne B. Venters. M.D."' (ORS) (919-353-1413) 

200 Doctors Dr.. Ste. J. Jacksonville 28540 

Consultants: 

Ms. Allene Cooley (NP) (919-748-4356) 

PA Prog.. Bowman Gray, Winston-Salem 

27103 
Ms. Kae Enright (PA) (919-684-8111) 

Duke Med. Ctr.. Box 3056, Durham 27710 
Ms. Esteie Fulp, RN, Chief Nurse (919-733-3131) 

Div. Health Services, P.O. Box 2091. Raleigh 27602 
Mr. James Hill (PA) (704-847-5447) 

9801 Sardis Oaks Rd.. Matthews 28105 
Mr. Bryant D. Paris. Executive Secretary (919-833-5321) 

Board of Medical Examiners. 222 N. Person St.. Ste. 214. 

Raleigh 27601 



Committee on Arrangements III-2 (12) 

Jack Hughes. M.D.'- (U) Chairman (919-286-1297) 

923 Broad St.. Durham 27705 
Henry J. Carr. Jr.. M.D.'*- (IM) (919-592-61 14) 

603 Beaman St.. Clinton 28328 
William B. Costenbader. Jr.. M.D." (OTO) (704-254-3517) 

131 McDowell St.. Asheville 28801 
Mrs. A. J. Crutchfield (Peggy) (Auxiliary) (919-766-4585) 

Rt. 3. Box 848. Clemmons 27012 
Eugene D, Furth. M.D.'-" (END) (919-757-4633) 

ECU, Dept. of Med., Greenville 27834 
Gloria F. Graham, M.D."" (D) (919-291-5600) 

702 Broad St., Wilson 27893 
Edna Hoffman, M.D.-" (919-485-8801) 

348 Valley Rd.. Fayetteville 28305 
James D. Hundley, M.D."'' (ORS) (919-763-7344) 

2001 S. 17th St., Wilmington 28401 
Robert S. Lackey, M,D,"" (R) (704-373-2274) 

2118 Pinewood Circle. Charlotte 2821 1 
Emery C. Miller. Jr.. M.D.''-' (END) (919-748-4145) 

Bowman Gray. Winston-Salem 27103 
J. Flint Rhodes. M.D.»- (U) (919-781-7113) 

2800 Blue Ridge Blvd.. Ste. 403. Raleigh 27607 
William B. Wood. M.D.'= (PUD) (919-933-2118) 

UNC. 231 MacNider BIdg.. Chapel Hill 27514 



4. Committee Advisory to Auxiliary III-3 (5) (2 Consultants) 

Rose Pully. M.D.''^ (FP) C/ia/rm((/; (919-523-2569) 

318 College St.. Kinston 28501 
Don C. Chaplin. M.D.' (IM) (919-227-3621) 

Kernodle Clinic. Burlington 27215 
Edna Hoffman, M.D.-" (919-485-8801) 

348 Valley Rd.. Fayetteville 28305 
Hampton Hubbard. M.D."= (U) (919-592-7129) 

Woodside Prof. BIdg.. Clinton 28328 
O. Raymond Hunt. Jr., M.D."'' (CDS) (919-763-6571) 

1607 Doctors Circle. Wilmington 28401 

Consultants: 

Mrs. Hal J. Rollins. Jr. (Ann) 

(Auxiliary Past-President) (919-274-3628) 

2011 Pembroke Rd., Greensboro 27408 
Mrs. Robert L. Means (Mary Jane) (Auxiliary ) (919-924-9911 

4001 Philpark Dr., Winston-Salem 27106 

5. Committee on Blue Shield IV-1 (31) 

Walter M. Roufail. M.D.-'^ (GE) Chairman (919-725-8326) 

2240 Cloverdale Ave., Ste. 88. Winston-Salem 27103 
Jose A. Bardelas. Jr., M.D.-" (A) (919-883-1393) 

624 Quaker Ln.. Ste. A-109. High Point 27262 
.lack W. Bonner. III. M.D." (P) (704-254-3201) 

Highland Hospital. P.O. Box 1101. Asheville 28802 
William S. Bost. Jr.. M.D."-' (OTO) (919-752-5227) 

P.O. Box 5007. #8 Doctor's Park. Greenville 27834 
E. B. Coley, M.D.'" (PD) (919-739-3318) 

103 W. 27th St., Lumberton 28358 
James P. Culley, M.D."- (GS) (919-576-5511) 

Drawer D, Troy 27371 
Arthur E. Davis, Jr., M.D.»- (PTH) (919-833-9839) 

1209 Cowper Dr.. Raleigh 27608 
R. Dale Ensor. M.D."" (U) (704-372-5180) 

1333 Romany Rd.. Charlotte 28204 
John E. Flournoy, M.D."^ (R) (919-527-7077) 

400 Glenwood Ave.. Kinston 28501 
William W. Fore. M.D."^ (IM) (919-752-6101 » 

1705 W. Sixth St.. Greenville 27834 
James C. Gaither, M.D.'" (IM) (704-322-1128) 

Rt. 2, Box 112. Conover 28613 
Frederick W. Glass. M.D.-'-' (EM) (919-748-4626) 

Bowman Gray. Winston-Salem 27103 
Cari J. Hiller. M.D.='' (ORS) (919-633-3256) 

P.O. Drawer 1694. New Bern 28560 
Gregory G. Holthusen. M.D." (ORS) (919-768-1270) 

1425 Plaza Dr.. Winston-Salem 27103 
Thomas H. Irving. M.D.^-i (AN) (919-748-4497) 

Bowman Gray. Dept. Anes.. Winston-Salem 27103 
Frederic R. Kahl. M.D." (CD) (919-748-4261) 

2626 Forest Dr., Winston-Salem 27104 
Edwin H. Martinat, M.D.-" (ORS) (919-773-3782) 

3333 Silas Creek Pkwy., Winston-Salem 27103 
William B. McCutcheon. Jr.. M.D.''" (TS) (919-383-5531) 

1830 Hillandale Rd.. Durham 27705 
Leslie M. Morris. M.D.'" (R) (704-864-4378) 

P.O. Box 1495. Gastonia 28052 
H. Maxwell Morrison. Jr.. M.D."'' (OPH) (919-295-6809) 

P.O. Box 460. Pinehurst 28374 
Joseph A. Moylan. M.D.== (GS) (919-684-2237) 

Duke Med. Ctr.. Box 3056. Durham 27710 
Timothy Pennell. M.D." (GS) (919-748-4671) 

Bowman Gray. Dept. of Surg.. Winston-Salem 27103 
Robert E. Price. Jr.. M.D." (NS) (919-383-5531) 

1830 Hillandale Rd.. Durham 27705 
Bobby A. Rimer. M.D."" (OBG) (704-373-3149) 
Charlotte Mem. Hosp.. P.O. Box 32861. Charlotte 28232 



600 



Vol. 42. No. 8 



I 



Leon W. Robertson, M.D." (FP) (919-443-8810) 

107 Medical Arts Mall, Rocky Mount 27801 
Wilbur T. Shearin, Jr., M.D.«'> (U) (919-763-6251) 

1905 Glen Meade Rd., Wilmington 28403 
Edward V. Staab, M.D.^- (NM) (919-966-5233) 

605 Churchill Dr., Chapel Hill 27514 
Joseph W. Stiefel, M.D.^' (Nl (919-273-25111 

200 E. Northwood St.. Ste. 508. Greensboro 27401 
James R. Urbaniak. M.D.-'- (ORS) (919-684-2476) 

Duke Hospital, Box 2912, Durham 27710 
Andrew W. Walker, M.D."" (PS) (704-372-6846) 

2215 Randolph Rd., Charlotte 28207 
S. Terry Withers, M.D.^^ (D) (919-523-3289) 

905 N. Queen St., Kinston 28501 

6. Committee on Cancer II-2 (12) (Legal — 1 ea. Congressional 
District) (6 Consultants) 

Charles L. Spurr. M.D." (ON) Chairman (919-748-4464) 

Bowman Gray. Winston-Salem 27103 
Ray G. Silverthome. M.D.' (OBG) (1st) (919-946-4101) 

408 E. 12th St.. Washington 27889 
Margaret Ann Nelsen, M.D.^^ (ON) (2nd) (919-851-8888) 

101 Blueridge Rd., Cartboro 27510 
John E. Prevette, M.D." (OBG) (3rd) (919-934-8548) 

601 -A Eighth St., Smithfield 27577 
Walter E. Davis, M.D.^- (ON) (4th) (919-383-5531) 

1830 Hillandale Rd., Durham 27705 
M. Robert Cooper. M.D.""" (HEM) (5th) (919-748-4300) 

330 Staffordshire Rd.. Winston-Salem 27104 
Kenneth S. Karb, M.D.-" (ON) (7th) (919-272-2141) 

1007 Prof. Village. Greensboro 27401 
William H. Newman, M.D.-« (GS) (7th) (919-484-4106) 

3427 Melrose Rd., Fayetteville 28304 
Richard W. Martin, M.D."*" (GS) (8th) (704-637-2750) 

P.O. Box 1665. Salisbury 28144 
Samuel L. Orr. M.D."" (PTH) (9th) (704-373-2251) 

Charlotte Mem. Hosp.. P.O. Box 32861. Charlotte 28232 
Avery W. McMurray, M.D.=^ (GS) (10th) (704-482-6359) 

207 Lee St.. Shelby 28150 
John F. Tannehill. M.D." (OTO) (11th) (704-452-1406) 

120 Hospital Dr., Clyde 28721 

Consultants: 

Timothy E. Cloninger. M.D."" (TR) (704-373-2272) 

P.O. Box 32861, Charlotte 28232 
Daniel L. Crocker, M.D." (ON) (919-443-9084) 

100 Nash Medical Arts Mall. Rocky Mount 27801 
Walter J. Pories, M.D." (GS) (919-757-4629) 

203 Chowan Rd., Greenville 27834 
William W. Shingleton, M.D.^^ (GS) (919-684-2282) 

Duke Med. Ctr., Box 3814, Durham 27710 
John Sterchi, M.D." (GS) (919-748-4276) 

Bowman Gray, Dept. Surg.. Winston-Salem 27103 
Leslie A. Walton. M.D.'= (OBG) (919-966-1194) 

N.C. Mem. Hosp., Dept. OB-GYN, Chapel Hill 27514 

Committee on Child Health & Infectious Diseases VI-1 (16) 
William L. London. M.D.^'- (PD) Chairman (919-688-6349) 

306 S. Gregson St., Durham 27701 
Marshall E. Agner, M.D.^" (FP) (704-435-6058) 

609 E. Academy St., Cherry ville 28021 
Lewis L. Bock, M.D."- (PD) (919-733-3816) 

Lenox Baker Children's Hosp., 

3000 Ervin Rd., Durham, N.C. 27705 
Harne R. Chamberlin, M.D."= (PD) (919-966-4417) 

UNC, Dept. Ped., Chapel Hill 27514 
George C. Debnam, M.D."- (GP) (919-832-1667) 

524 S. Blount St., Raleigh 27601 



jo, August 1981, NCMJ 



E. Stephen Edwards, M.D.''- (PD) (919-781-7490) 

2800 Blue Ridge Blvd., Ste. 501, Raleigh 27607 
Thomas E. Frothingham. M.D.'>- (PD) (919-684-5797) 

Duke Med. Ctr., Box 3937. Durham 27710 
Rufus M. Herring, Jr., M.D."- (PD) (919-592-6011) 

403 Fairview St.. Clinton 28328 
Wilks O. Hiatt, Jr., M.D."= (PH) (919-847-0432) 

7812 Harps Mill Rd., Raleigh 27609 
Josephine T. Melchoir. M.D."" (PD) (919-443-8858) 

HI Med. Arts Mall, Rocky Mount 27801 
Brtice A. Phillips, Jr., M.D." (IM) (919-862-3212) 

P.O. Box 86, Elizabethtown 28337 
Jimmie L. Rhyne, M.D."= (PH) (919-733-7791) 

Div, of Health Services, P.O. Box 2091, Raleigh 27602 
Charles K. Scott, M.D.' (PD) (919-228-8316) 

530 W. Webb Ave.. Burtington 27215 
Jimmy Simon, M.D.'^ (PD) (919-748-4431) 

Bowman Gray, Dept. of Ped., Winston-Salem 27103 
G. Eari Trevathan, Jr., M.D.'^ (PD) (919-757-2733) 

ECU, Dept. of Ped.. Greenville 27834 
Sara Lou Warren, M.D,"= (FP) (919-966-2491) 

N.C. Mem. Hosp., Chapel Hill 27514 



8. Committee on Communications V-1 (9) (6 Consultants) 

Elizabeth P. Kanof, M.D."- (D) Chairman (919-833-3672) 

1300 St. Mary's St.. Raleigh 27605 
Verna Y. Barefoot, M.D.-' (PH) (919-633-4121) 

2504 Old Cherry Point Rd., New Bern 28560 
Don C. Chaplin, M.D.' (IM) (919-277-3621) 

Kernodle Clinic, Burlington 27215 
Josephine T. Melchoir, M.D."" (PD) (919-443-8858) 

111 Med. Arts Mall, Rocky Mount 27801 
Stanley B. Levy, M.D. 3- (D) (919-942-3106) 

861 Willow Dr., Chapel Hill 27514 
A, Sherman Morris, Jr., M.D." (OBG) (704-255-8900) 

62 Orange St.. Asheville 28801 
J. Jerome Pence, Jr., M.D."'' (FP) (919-763-3481) 

2305 Parham Rd.. Wilmington 28401 
Nelson B. Watts. M.D." (END) (704-254-0771) 

93 Victoria Rd.. Asheville 28801 
Jack W. Wilkerson, M.D.'^ (FP) (919-752-7133) 

P.O. Box 1966, Greenville 27834 

Consultants: 

Mrs. G. Walker Blair, Jr. (Sara Jo) (Auxiliary) (919-226-4888) 

1904 W. Lake Dr., Burlington 27215 
Mrs. Hampton Hubbard (Anne) (Auxiliary President) 

(919-592-7885) 

102 Country Club Circle, Clinton 28328 
Mrs. O. Raymond Hunt (Eleanor) (.Auxiliary President-Elect) 

(919-762-6015) 

1713 S. Live Oak Pkwy.. Wilmington 28403 
Mrs. John Lyday (Irma) (.Auxiliary) (919-288-5155) 

2819 St. Regis Rd.. Greensboro 27408 
Ms. June Milby (919-733-4471) 

Dept. of Human Resources, 325 N. Salisbury St., Raleigh 

27611 
Mr. David L. Reynolds (919-541-9090) 

Burroughs Wellcome Co., 3030 Comwallis Rd., 

Research Triangle 27709 



9. Committee on Constitution & Bylaws III-4 (5) 

P. G. Fox. Jr., M.D."- (U) Chairman (919-876-4323) 

P.O. Box 17908, Raleigh 27619 
Henry J. Carr, Jr.. M.D."- (IM) (919-592-6114) 

603 Beaman St., Clinton 28328 



601 



Hector H. Henry, II. M.D.'= (U) (704-786-5133) 
102 Lake Concord Rd., NE, Concord 28025 

Louis deS. Shaffner. M.D." (PDS) (919-748-4502) 
Bowman Gray. Winston-Salem 27103 

Howard E. Strawcutter, M.D.'" (U) (919-738-7166) 
101 W. 27th St., Lumberton 28358 



10. Council on Review & Development (10) (4 Ex OfTicio with Vote) 
(1 non-voting) 

J. B. Warren. M.D.-' (FP) Chairman (919-637-6193) 
P.O. Box 1465. New Bern 28560 

D. E. Ward, Jr., M.D."» (GS) Vke-Chainnun (919-738-4276) 
2604 N. Elm St.. Lumberton 28358 

E. Harvey Estes, Jr.. M.D.^'- (IM) (919-684-5314) 
Duke Med. Ctr.. Box 2914. Durham 27710 

Jesse Caldwell, Jr., M.D.'^'' (GYN) (704-865-0968) 

1307 Park Lane, Gastonia 28052 
James E. Davis, M.D."- (GS) (919-471-8439) 

2609 N. Duke St., Ste. 402. Durham 27704 
Frank R. Reynolds. M.D.'''' (PD) (919-763-4272) 

1613 Dock St.. Wilmington 28401 
George G. Gilbert. M.D." (U) (704-253-5314) 

1 Doctor's Park. Asheville 28801 
John Glasson. M.D.''- (ORS) (919-471-8431) 

2609 N. Duke St., Ste. 301. Durham 27704 
Charles W. Styron, M.D.'^ (IM) (919-828-7773) 

615 St. Mary's St., Raleigh 27605 
Louis deS. Shaffner, M.D." (PDS) (919-748-4502) 

Bowman Gray, Winston-Salem 27103 

Ex Officio with Vote: 

Frank Sohmer, M.D." (GE) (Past President) (919-725-8326) 

2240 Cloverdale Ave.. Ste. 88, Winston-Salem 27103 
Josephine E. Newell. M.D."» (FP) (President) (919-833-3836) 

Raleigh Townes. Apt. 47. 525 Wade Ave.. Raleigh 27605 
Marshall S. Redding, M.D.'" (OPH) (President-Elect) 

(919-335-5446) 

1142 N. Road St., Ehzabeth City 27909 
Jack Hughes, M.D.^- (U) (Secretary) (919-286-1297) 

923 Broad St.. Durham 27705 

Ex Officio Non-Voting: 

William N. Hilliard (Executive Director) (919-833-3836) 
P.O. Box 27167. Raleigh 27611 



11. Committee on Credentials (of Delegates to House of Delegates) 
I1I-5 (4) 

Louis R. Wilkerson. M.D.''- (OBG) Chairman (919-832-5529) 

100 S. Boylan Ave.. Raleigh 27603 
W. Otis Duck. M.D.'' (FP) (704-689-2.581) 

Drawer F, Mars Hill 28754 
Charles H. Duckett. M.D.-" (FP) (919-748-4479) 

Bowman Gray. Dept. Fam. Med.. Winston-Salem 27103 
Carey J. Walton. Jr., M.D.'^ (IM) (704-758-5544) 

315-A Mulberry St.. SW, Lenoir 28645 



12. Committee Advisory to Crippled Children's Program IV-2 (15) 
David R. Williams, M.D.-" (PD) Chairman (919-475-2348) 

Southgate Shopping Ctr.. Thomasville 27360 
Page Anderson, M.D."- (PDC) (919-684-2538) 

Duke Med. Ctr., Box 3218, Durham 27710 
Ralph W. Coonrad, M.D."- (ORS) (919-286-1249) 

1828 Hillandale Rd.. Durham 27705 
Gregory G. Holthusen. M.D." (ORS) (919-768-1270) 

1425 Plaza Dr.. Winston-Salem 27103 



602 



Angus M. McBryde, Jr.. M.D.*"' (ORS) (704-373-0544) 

1822 Brunswick Dr.. Charlotte 28207 
William W. Morgan. Jr.. M.D." (PDS) (704-274-4105) 

P.O. Box 15083. Asheville 28813 
Jerry M. Petty. M.D.*"' (NS) (704-376-1606) 

1012 Kings Dr., Ste. 101, Charlotte 28283 
M. Brent Seagle. M.D." (OTO) (919-638-2616) 

2507 Neuse Blvd., New Bern 28560 
J. Baldwin Smith, 111, M.D.'" (N) (919-768-5834) 

201 Executive Park Blvd.. Winston-Salem 27103 
William C. Trier. M.D.'- (PS) (919-966-4446) 

UNC. Div. of Plastic Surg.. Chapel Hill 27514 
T. Reed Underbill. M.D." (U) (919-633-2712) 

800 Hospital Dr., Ste. 4. New Bern 28560 
Kelley Wallace, Jr.. M.D.'^ (PS) (919-752-1406) 

1705 W. Sixth St., Greenville 27834 
Richard L. Weaver, M.D." (NPM) (919-727-4663) 

2116 Leeds Rd.. Winston-Salem 27103 
Robert L. Young, Jr., M.D,'^ (PD) (919-739-3318) 

103 W. 27th St.. Lumberton 28358 

13. Committee on Disaster & Emergency Medical Care V-2 (16) 

(1 Consultant) 

Joseph A. Moylan. M.D."- (GS) Chairman (919-684-2237) 

Duke Med. Ctr.. Box 3056, Durham 27710 
William P. Brown. Jr.. M.D."'' (NS) (919-765-3750) 

2570 Club Park Rd.. Winston-Salem 27104 
John N. Ellis. M.D."" (ORS) (919-295-6831) 

Pinehurst Surgical Clinic, Pinehurst 28374 
Frederick W. Glass. M.D." (EM) (919-748-4676) 

Bowman Gray, Winston-Salem 27103 
Douglas I. Hammer, M.D."' (EM) (919-782-5488) 

P.O. Box 30788. Raleigh 27622 
George Johnson, Jr., M.D.'- (GS) (919-966-3391) 

N.C. Mem. Hospital. Chapel Hill 27514 
David L. Kelly. Jr.. M.D."^ (NS) (919-748-4049) 

Bowman Gray. Winston-Salem 27103 
Robert E. Miller. M.D."" (ORS) (704-373-0544) 

1822 Brunswick Ave.. Chariotte 28207 
Donald T. Moore. M.D."= (OBG) (919-5%-8185) 

920 Chowan Ave.. Durham 27703 
Richard E. Morgan. M.D." (GS) (919-633-2081) 

403 Melody Lane, New Bern 28560 
Henry H. Nicholson, Jr., M.D."" (GS) (704-375-8956) 

1012 Kings Dr., Ste. 708, Charlotte 28283 
George Podgomy, M.D."^ (EM) (919-727-1161) 

2115 Georgia Ave.. Winston-Salem 27104 
Charles G. Rob. M.D.'^ (GS) (919-756-8131) 

230 Country Club Dr.. Greenville 27834 
Llewellyn W. Stringer, M.D." (PUD) (919-765-7517) 

1728 Hawthorne Rd.. Winston-Salem 27103 
Andrew W. Walker. M.D."" (PS) (704-372-6846) 

2215 Randolph Rd.. Charlotte 28207 
Richard L. Weaver. M.D."-" (NPM) (919-727-4663) 

2116 Leeds Lane, Winston-Salem 27103 

Consultant: 

Mr. Thomas M. Harmelink. Chief (919-733-2285) 
Office of Emergency Med. Serv.. P.O. Box 12200, 
Raleigh 27605 

14. Committee on Drug Abuse & Pharmacy VI-2 ( 10) (6 Consultants) 

John A. Ewing. M.D."= (P) Chairman (919-966-4551) 

N.C. Mem. Hospital. Chapel Hill 27514 
Roy J. Blackley. M.D."- (P) (919-733-701 1 ) 

Dept. of Human Resources. 325 N. Salisbury St., 

Raleigh 27611 

Vol. 42. No. 8 



i 



Marianne S. Breslin. M.D.^^ (P) (919-684-5758) 

Duke Med. Ctr.. Box 3837, Durham 27710 
Malcolm Fleishman, M.D.-« (IM) (919-484-0144) 

P.O. Box 35126. Fayetteville 28302 
W, J. K. Rockwell. M.D." (P) (919-684-3073) 

Duke Med. Ctr.. Dept. of Psy., Durham 27710 
Llewellyn W. Stringer, M.D.^-" (PUD) (919-765-7517) 

1728 S. Hawthorne Rd.. Winston-Salem 27103 
Horatio P. Van Cleve. M.D.^'' (FP) (919-748-4479) 

604 Archer Rd., Winston-Salem 27106 
Robert W. Whitener. M.D." (P) (919-274-1250) 

1024 Professional Village. Greensboro 27401 
Robert E. Williford. M.D.'" (FP) (919-625-4000) 

208 Foust St., Asheboro 27203 
W. Samuel Yancey, M.D.»= (PD) (919-688-6349) 

306 S. Gregson St., Durham 27701 

Consultants: 

Lt. Col. Jack F. Cardwell (919-733-7952) 

N.C. Highway Patrol, P.O. Box 27687. Raleigh 27611 
Mr. F. E. (Roy) Epps (919-733-4555) 

Div. of Mental Health & Retardation. 3800 Barrett Dr., 

Raleigh 27609 
Mrs. Lady Faircloth (919-733-4670) 

Div. of Mental Health & Retardation. 325 N. Salisbury St.. 

Raleigh 27611 
Mr. A. H. Mebane. IlL Executive Director (919-967-2237) 

N.C. Pharmaceutical Assn., Drawer 151, Chapel Hill 27514 
Mr. Haywood R. Starling. Director (919-733-4311) 

SBI. P.O. Box 29500. Raleigh 27626 
Mr. David R. Work, Secretary-Treasurer (919-942-4454) 

N.C. Board of Pharmacy, P.O. Box 471. Chapel Hill 27514 

15. Committee on Ethics & Religion III-6 (10) (2 Consultants) 

Gloria F. Graham. M.D."" (D) Chairman (919-291-5600) 

702 Broad St., Wilson 27893 
Elms L. Allen, M.D.'^ (HEM) (919-765-4131) 

1405 Plaza Dr.. Winston-Salem 27103 
M. Robert Cooper. M.D." (HEM) (919-748-4300) 

330 Staffordshire Rd., Winston-Salem 27104 
Austin T. Hyde, Jr., M.D.»' (A) (704-286-9036) 

P.O. Box 970, Rutherfordton 28139 
Marjorie E, F, Matthews, M,D.»« (FP) (919-368-4198) 

P,0. Box 667, Pilot Mountain 27041 
John S. Rhodes, M.D."= (U) (919-833-4582) 

1617 Oberlin Rd., Raleigh 27608 
Louis deS. Shaffner, M.D.^-* (GS) (919-748-4502) 

Bowman Gray, Winston-Salem 27103 
Lewis S. Thorp, M.D." (FP) (919-443-9084) 

100 Medical Arts Mall. Rocky Mount 27801 
Charles B. Wilkerson. Jr.. M.D.»- (IM) (919-834-1051) 

102 S. Boylan Ave., Raleigh 27603 
Lucien S. Wilkins, M.D.«^ (GE) (919-763-8251) 

1202 Medical Center Dr.. Wilmington 28401 

Consultants: 

Mrs. Hampton Hubbard (Anne) (Auxiliary President) 

(919-592-7885) 

102 Country Club Circle. Clinton 28328 
Harmon Smith. Ph.D. (919-489-0022) 

The Divinity School, Duke University. Durham 27706 

16. Committee on Eye Care & Eye Bank V-3 (15) 

Albin W. Johnson, M.D.»= (OPH) Chairman (919-781-7400) 
2800 Blue Ridge Blvd., Ste. 409, Raleigh 27607 

Charles L. Baltimore. Jr., M.D." (OPH) (919-946-2171) 
P.O. Box 879, Washington 27889 

August 1981, NCMJ 



Frederick C. Butler, Jr.. M.D."'' (OPH) (919-763-3601) 

1915 Glen Meade Rd.. Wilmington 28401 
Lee A. Clark, Jr., M.D.''" (OPH) (919-291-7001) 

Wilson Clinic, Wilson 27893 
Andrew Davidson, M.D.--^ (OPH) (919-633-4183) 

P.O. Box 250, New Bern 28560 
Robert E. Dawson. M.D.'- (OPH) (919-682-7175) 

512 Simmons St.. Durham 27701 
Baird S. Grimson. M.D.'= (OPH) (919-966-5296) 

UNC. 617 Clinical Science Bldg.. 229-H, Chapel Hill 27514 
Edward K. Isbey, Jr.. M.D." (OPH) (704-258-1586) 

495 Biltmore Ave., Asheville 28801 
Charles G. Kirby, M.D.^" (OPH) (704-872-0961) 

925 Thomas St.. Statesville 28677 
John W. Reed. M.D." (OPH) (919-748-4091) 

Bowman Gray, Dept. of Oph., Winston-Salem 27103 
M. Bruce Shields, M.D.'= (OPH) (919-684-2841) 

Duke University Eye Ctr.. Durham 27710 
James B. Sloan, M,D.«' (OPH) (919-763-3601) 

1915 Glen Meade Rd.. Wilmington 28401 
J. David Stratton, M.D."" (OPH) (704-364-8576) 

3535 Randolph Rd.. R-202. Charlotte 28211 
Shahane R. Taylor. Jr.. M.D."" (OPH) (919-274-4626) 

348 N. Elm St., Greensboro 27401 
David W. White, M.D." (OPH) 

624 Quaker Ln., Ste. 202-C. High Point 27262 

17. Committee on Finance I-l (6) (7 Consultants) 

Ernest B. Spangler. M.D.^' {,K) Chairman (919-855-8972) 

Drawer X-3. Greensboro 27402 
Thomas B. Dameron. Jr., M.D.»= (ORS) (919-781-5600) 

P.O. Box 10707. Raleigh 27605 

E. Thomas Marshburn. Jr.. M.D."' (IM) (919-762-9621) 
3208 Oleander Dr., Wilmington 28401 

Charles T. McCullough, Jr., M.D." (ORS) (704-254-9504) 
Bone & Joint Clinic. Doctor's Dr., Asheville 28801 

Thomas F. O'Brien. Jr.. M.D." (GE) (919-757-4652) 
ECU Sch. of Med., Greenville 27834 

Shahane R. Taylor. Jr.. M.D." (OPH) (919-274-4626) 
348 N. Elm St., Greensboro 27401 

Consultants: 

Thomas B. Dameron, Jr., M,D.»2 (ORS) (919-781-5600) 
P.O. Box 10707. Raleigh 27605 

F. Maxton Mauney, Jr.. M.D," (CDS) (704-258-1121) 
257 McDowell St.. Asheville 28803 

Gloria F. Graham. M.D."* (D) (919-291-5600) 

702 Broad St., Wilson 27893 
Charles A. Hoffman, Jr.. M.D.'-" (U) (919-485-8801) 

513 Owen Dr., Fayetteville 28304 
John L. McCain, M.D."" (RHU) (919-291-7001) 

Wilson Clinic, Wilson 27893 
Rose Pully, M.D.'^ (FP) (919-523-2569) 

318 College St., Kinston 28501 
T. Tilghman Herring. M.D."" (OM) (919-291-7001) 

Wilson Clinic. Wilson 27893 

18. Representative on Governor's Advisory Council on Aging (1) 
(4-year term) 

Joseph J. Combs. M.D."- (IM) (1985) (919-787-9032) 
2125 White Oak Rd., Raleigh 27608 

19. Committee on Health Planning & Development IV-3 (16) 

William E. Laupus. M.D." CP\i) Chairman (919-757-4627) 
ECU. Dean's Office. Greenville 27834 (HSA Region VI) 

Lloyd W. Bailey. M.D.""' (OPH) (919-443-5164) 
109 Foy Dr., Rocky Mount 27801 



603 



John D. Bridgers. Sr.. M.D.^' (PD) (919-882-4171) 

624 Quaker Lane. Ste. 200-A. High Point 27262 
W. Lester Brooks. Jr.. M.D.''" (IM) (704-333-4175) 

18.51 E. Third St.. Charlotte 28204 (HSA Region III) 
Thornton R. Cleek. M.D."' (FP) (919-629-2387) 

379 S. Cox St., Asheboro 27203 
James E. Davis, M.D.-" (GS) (919-471-8439) 

2609 N. Duke St.. Ste. 402. Durham 27704 
Paul Green, Jr., M.D."" (OBG) (704-636-9270) 

315 Mocksville Ave.. Salisbury 28144 
T. Reginald Harris. M.D.--' (PUD) (704-482-1482) 

808 Schenck St., Shelby 28150 (HSA Region 1) 
Charles A. Hoffman. Jr.. M.D.-'' (U) (919-485-8801) 

513 Owen Dr.. Fayetteville 28304 
John L. McCain. M.D."" (RHU) (919-291-7(K)1) 

Wilson Clinic, Wilson 27893 
J. Jerome Pence, Jr., M.D.''-' (FP) (919-763-3481) 

2305 Parham Rd.. Wilmington 28401 
George Podgorny. M.D.-" (EM) (919-727-1161) 

21 15 Georgia Ave., Winston-Salem 27104 
Waller M. Roufail, M.D.-» (GE) (919-72.5-8326) 

2240 Cloverdale Ave.. Ste. 88. Winston-Salem 27103 

(HSA Region II) 
Howard E. Strawcutter. M.D."" (U) (919-738-7166) 

101 W. 27th St.. Lumberton 283.58 (HSA Region V) 
John W. Watson. M.D.-'" (FP) (919-693-8126) 

104 New College St., Oxford 27565 (HSA Region IV) 
Jerry C. Woodard, M.D."" (GE) (919-291-1300) 

Carolina Clinic. Wilson 27893 

20. Committee Liaison to Department of Human Resources IV-7 (II) 

Julian F. Keith. Jr., M.D." (FP) Chairman (919-748-2251) 

Bowman Gray, Dept. of Family Med.. Winston-Salem 27103 
John R. Ashe, Jr., M.D." (OBG) (704-788-4151) 

1054 Burrage Rd.. NE, Concord 28025 
Thornton R. Cleek. M.D."'^ (FP) (919-629-2387) 

379 S. Cox St.. Asheboro 27203 
Elwood B. Coley. M.D.'" (PD) (919-739-3318) 

103 W. 27th St.. Lumberton 28358 
E. Harvey Estes. Jr.. M.D.'- (IM) (919-684-5314) 

Duke Med. Ctr., Box 2914. Durham 27710 
Ronald H. Levine, M.D."- (PH) (919-782-0838) 

2404 White Oak Rd.. Raleigh 27609 
Jesse H. Meredith, M.D." (GS) (919-748-4278) 

Bowman Gray. Dept. of Surgery, Winston-Salem 27103 
Talbot F. Parker, Jr., M.D."" (OBG) (919-7.34-3.344) 

2400 Wayne Mem. Dr.. Ste. K, Goldsboro 27530 
William D. Rippy. M.D.' (FP) (919-226-4471) 

1610 Vaughn Rd.. Burlington 27215 
Joseph D. Russell. M.D."" (IM) (919-291-L300) 

Carolina Clinic, Wilson 27893 
G. Earl Trevathan, Jr.. M.D." (PD) (919-757-2733) 

ECU. Dept. of Fed.. Greenville 27834 

21. Committee to Work with N.C. Industrial Commission IV-4 (18) 
Thomas E. Castelloe, M.D."- (ORS) Chuinnan (919-781-5600) 

P.O. Box 10707. Raleigh 27605 
James S. Fulghum, III, M.D.»- (NS) (919-832-4448) 

P.O. Box 14027, Raleigh 27610 
John T. Daniel, Jr., M.D.'= (GS) (919-682-7378) 

415 Dunstan St., Durham 27707 
Thomas R. Giblin, M.D."" (PS) (704-333-4161) 

190 Randolph Rd.. Ste. 300. Charlotte 28207 
Benjamin W. Goodman. M.D.'" (FP) (704-328-2231) 

24 Second Ave., NE, Hickory 28601 
Ralph L. Greene, Jr., M.D.«" (IM) (704-365-0760) 

3535 Randolph Rd., Charlotte 28211 



604 



Elzie F. Hart. Jr., M.D.'= (OTO) (704-433-6410) 

3.50 E. Parker Rd.. Morganton 28655 
T. Tilghman Herring. M.D."" (OM) (919-291-7001) 

Wilson Clinic. Wilson 27893 
Carl J. Hiller, M.D.-^^ (ORS) (919-633-32.56) 

P.O. Drawer 1694. New Bern 28560 
Julius Howell, M.D." (PS) (919-748-4171) 

Bowman Gray, Winston-Salem 27103 
Thomas J. Koontz, M.D.'^ (GS) (919-765-.5221) 

42.50 Allistair Rd.. Winston-Salem 27104 
Raymond D. Kornegay. M.D."= (CDS) (919-782-7900) 

2800 Blue Ridge Blvd.. Ste. 306. Raleigh 27607 
Paul D. Long. M.D.-" (ORS) (919-275-0927) 

1505 Pembroke Rd., Greensboro 27408 
Robert E, Miller, M.D."" (ORS) (704-37.3-0544) 

1822 Brunswick Ave., Charlotte 28207 
Charles L. Nance, Jr.. M.D."-' (ORS) (919-763-7344) 

2001 S. 17th St., Wilmington 28401 
Richard C. Proctor, M.D." (P) (919-748-4552) 

Bowman Gray. Winston-Salem 27103 
J. Flint Rhodes. M.D."- (U) (919-781-7113) 

2800 Blue Ridge Blvd., Ste. 403. Raleigh 27607 
M. Brent Seagle. M.D.-' (OTO) (919-638-2616) 

2507 Neuse Blvd., New Bern 28.560 

22. Committee to Investigate Various Insurance Plans 1-2 (3) 

Jesse Caldwell. Jr.. M.D.^" (GYN) Chairman (704-865-0968) 

1307 Park Lane, Gastonia 28052 
Timothy E. Cloninger, M.D."" (TR) (704-373-2272) 

P.O. Box 32861. Charlotte 28232 
T. Reginald Harris. M.D.-' (PUD) (704-482-1482) 

808 Schenck St.. Shelby 281.50 

23. Committee Advisory to Jail Project VI-3 (6) 

Philip G. Nelson, M.D.'^ (P) Chairman (919-758-3145) 

Medical Pavilion, Ste. 9. Greenville 27834 
George C. Debnam, M.D."= (GP) (919-832-1667) 

524 S. Blount St., Raleigh 27601 
Susan S. Gustke, M.D."- (IM) (919-733-5431) 

4100 Stranaver PI.. Raleigh 27612 
R. Page Hudson. Jr., M.D.'= (FOP) (919-966-22.53) 

Chief Med. Examiner's Office. 

P.O. Box 2488, Chapel Hill 27514 
Rose Pully, M.D.-" (FP) (919-523-2.569) 

318 College St.. Kinston 28501 
Stephen C. Rochman. M.D.-" (U) (919-485-8801) 

513 Owen Dr.. Fayetteville 28304 

24. Committee on Legislation V-4 (38) (3 Consultants) (*Executive 
Committee) 

■^Don C. Chaplin, M.D.' (IM) Chairman (919-227-3621) 

Kernodle Clinic, Burlington 27215 
*W. Grimes Byeriy. Jr.. M.D.'" (GS) (704-328-2231) 

24 Second Ave.. NE, Hickory 28601 
*Joseph W. Hooper, Jr., M.D.""' (U) (919-763-6251) 

1905 Glen Meade Rd.. Wilmington 28403 
*F. Maxton Mauney. Jr.. M.D." (CDS) (704-2.58-1121) 

2.57 McDowell St.. Asheville 28803 
*Shahane R. Taylor, Jr., M.D.^' (OPH) (919-274-4626) 
348 N. Elm St., Greensboro 27401 
Neil C. Bender, M.D," (IM) (919-224-4591) 

P.O. Box 68. Pollocksville 28573 
Frank W. Browning. M.D." (OPH) (919-323-1800) 

1629 Owen Dr., Fayetteville 28304 
Franklin S. Clark. M.D." (GS) (919-323-2626) 

3316 Kentyre Dr., Fayetteville 28.303 
Elwood B. Coley, M.D.'" (PD) (919-739-3318) 
103 W. 27th St., Lumberton 28358 






Vol. 42, No. 8 



I 



Thomas B. Dameron, Jr., M.D/'- (ORS) (919-781-5600) 

P.O. Box 10707. Raleigh 27605 
J. Dewey Dorsett. Jr., M.D."" (IM) (704-333-4175) 

1851 E. Third St., Charlotte 28204 
W. Otis Duck. M.D.-^" (FP) (704-689-2581) 

Drawer F, Mars Hill 28754 
John A. Fagg, M.D." (PS) (919-765-8620) 

2901 Maplewood Ave., Winston-Salem 27103 
Susan S. Gustke, M.D."'- (IM) (919-733-5431) 

4100 Stranaver PI.. Raleigh 27612 
John H. Hall. M.D.^' (D) (919-274-3046) 

1100 Olive St., Greensboro 27401 
T. Reginald Harris, M.D." (PUD) (704-482-1482) 

808 Schenck St., Shelby 28150 
John A. Henderson, M.D." (OS) (704-254-2341) 

117 Rathfarnham Cir., Asheville 28803 
Hector H. Henry. II, M.D.'-' (U) (704-786-5133) 

102 Lake Concord Rd., NE, Concord 28025 
Charles A. Hoffman, Jr., M.D.-" (U) (919-485-8801) 

513 Owen Dr.. Fayetteville 28304 
Edna M. Hoffman, M.D." (919-485-8801) . 

348 Valley Rd.. Fayetteville 28305 
Hampton Hubbard. M.D.»- (U) (919-592-7129) 

Woodside Prof. BIdg.. Clinton 28328 
Jack Hughes. M.D.»= (U) (Secretary) (919-286-1297) 

923 Broad St.. Durham 27705 
Elizabeth P. Kanof. M.D."" (D) (919-833-3672) 

1300 St. Mary's St., Raleigh 27605 
Julian F. Keith. Jr.. M.D.-^^ (FP) (919-748-2251) 

Bowman Gray, Dept. of Earn. Med., Winston-Salem 27103 
Hervy B. Kornegay, Sr., M.D."" (FP) (919-658-4954) 

238 Smith Chapel Rd., Mt. Olive 28365 
Ronald H. Levine, M.D."- (PH) (919-782-0838) 

2404 White Oak Rd., Raleigh 27609 
R. William McConnell, M.D." (R) (919-752-5000) 

1711 W. Sixth St., Greenville 27834 
J. Doyle Medders, M.D."= (GP) (919-496-4250) 

113 Jolly St.. Louisburg 27549 
Josephine E. Newell. M.D."" (FP) (President) (919-833-3836) 

Raleigh Townes, Apt. 47. 525 Wade Ave.. Raleigh 27605 
Henry H. Nicholson, Jr.. M.D."" (OS) (704-375-8956) 

1012 Kings Dr.. Ste. 708, Charlotte 28283 
Charles A. Phillips. M.D.''^ (GS) (919-295-531 1) 

P.O. Box 430, Pinehurst 28374 
Milton D. Quigless, Jr., M.or- (GS) (919-821-5771) 

100 Sunnybrook Rd.. Raleigh 27610 
Marshall S. Redding, M.D.'" (OPH) (President-Elect) 

(919-335-5446) 1142 N. Road St.. Elizabeth City 27909 
Robert H. Shackelford. M.D."" (FP) (919-658-4954) 

238 Smith Chapel Rd.. Mt. Olive 28365 
Jimmy L. Simon, M.D.^^ (PD) (919-748-4431) 

Bowman Gray, Dept. Ped.. Winston-Salem 27103 
Frank Sohmer. M.D." (GE) (Past-President) (919-725-8326) 

2240 Cloverdale Ave.. Ste. 88. Winston-Salem 27103 
Thomas L. Speros, M.D.' (FP) (919-946-5293) 

123 Short Dr.. Washington 27889 
J. David Stratton. M.D."" (OPH) (704-364-8576) 

3535 Randolph Rd., R-202. Charlotte 28211 



Consultants: 

Mrs. Hampton Hubbard (Anne) (Auxiliary President) 
(919-592-7885) 102 Country Club Cir., Clinton 28328 

Mrs. O. Raymond Hunt (Eleanor) (Auxiliary) (919-762-6015) 
1713 S. Live Oak Pkwy., Wilmington 28403 

Mrs. Douglas Russell (Carolyn) (Auxiliary) (919-736-2665) 
304 Glen Oak Dr., Goldsboro 27530 



August 1981. NCMJ 



25. Committee on Maternal Health VI-4 (18) (6-yr. term) 
(1 Consultant) 

Robert G. Brame, M.D." (OBG) (ECU) (1985) Chairman 

(919-757-4610) ECU, Dept. of OB-GYN, Greenville 27834 
William A. Peters, Jr., M.D.'" (OBG) (1st) (1983) 

(919-335-2355) P.O. Box 392. Elizabeth City 27909 
H. Fleming Fuller. M.D."'^ (OBG) (2nd) (1987) (919-522-4333) 

Kmston Clinic. N.. Ste. E. Kinston 28501 
John W. Nance. M.D.«- (FP) (3rd) (1984) (919-592-601 1) 

403 Fairview St.. Clinton 28328 
John A. Kirkland, M.D.»» (OBG) (4th) (1982) (919-291-9010) 

Wilson Clinic. Wil.son 27893 
John C. Rozier. Jr.. M.D." (OBG) (5th) (1983) (919-738-9601 ) 

4300 Fayetteville Rd.. Lumberton 28358 
Clifford C. Byrum. M.D."-' (OBG) (6th) (1985) (919-782-0124) 

2800 Blue Ridge Blvd., Ste. 301. Raleigh 27607 
Joe Don Hughes. M.D."' (OBG) (7th) (1985) (704-287-7383) 

P.O. Box 1208. Rutherfordton 28139 
Karl L. Barkley. M.D." (OBG) (8th) (1983) (919-273-2835) 

1305 W. Wendover Ave.. Greensboro 27408 
Robert L. Rogers. Jr.. M.D.'^ (OBG) (9th) (1982) 

(704-758-2309) 308 Mulberry St.. SW. Lenoir 28645 
A. Sherman Morris. Jr.. M.D." (OBG) (10th) (1987) 

(704-255-8900) 62 Orange St.. Asheville 28801 
Lewis L. Bock. M.D."" (PD) (1985) (919-733-3816) 

Div. of Health Serv.. P.O. Box 2091, Raleigh 27602 
Robert P. Dillard, M.D." (PD) (919-757-2733) 

ECU. Dept. of Ped.. Greenville 27834 
Mary Susan Fulghum. M.D."- (OBG) (1987) (919-832-5529) 

100 S. Boylan Ave., Raleigh 27603 
William P. Herbert, M.D.'- (OBG) (UNO (1985) 

(919-966-1601) UNC. Dept. of OB-GYN. Chapel Hill 27514 
W. Joseph May. M.D." (OBG) (EG) (1982) (919-748-4595) 

300 S. Hawthorne Rd.. Winston-Salem 27103 
Richard R. Nugent. M.D.-'= (GPM) (1987) (919-733-2973) 

Div. of Health Serv., P.O. Box 2091. Raleigh 27602 
Joseph B. Parker. Jr.. M.D.'= (P) (DUKE) (1985) 

(919-684-5995) Duke Med. Ctr.. Box 3837, Durham 27710 

Consultant: 

Mrs. Hal Rollins, Jr. (Ann) (Auxiliary Past-President) 
(919-274-3628) 2011 Pembroke Rd., Greensboro 27408 



26. Mediation Committee (5) (Five Immediate Past-Presidents) 

Jesse Caldwell, Jr.. M.D.-'" (GYN) Chairman (704-865-0968) 

1307 Park Lane. Gastonia 28052 
Frank Sohmer, M.D.-" (GE) Secrelary- (919-725-8326) 

2240 Cloverdale Ave., Ste. 88. Winston-Salem 27103 
E. Harvey Estes. Jr.. M.D.-"= (CD) (919-684-5314) 

Duke Med. Ctr.. Box 2914. Durham 27710 
D. E. Ward. Jr.. M.D." (GS) (919-738-4276) 

2604 N. Elm St., Lumberton 28358 
J. B. Warren. M.D.-'' (FP) (919-637-6193) 

P.O. Box 1465. New Bern 28560 

27. Committee on Medical Aspects of Sports V-5 (19) (2 Consultants) 
Frank W. Clippinger. Jr.. M.D.'- (ORS) C/iu/rm«/i 

(919-684-4229) Duke Med. Ctr.. Box 3935, Durham 27710 
Frank H. Bassett. Ill, M.D.-'- (ORS) (919-684-4378) 

Duke Med. Ctr., Durham 27710 
Basil M. Boyd. Jr., M.D."" (ORS) (704-373-0544) 

1822 Brunswick Ave., Charlotte 28207 
Paul L. Burroughs. Jr.. M.D."- (ORS) (919-872-5296) 

P.O. Box 18136. Raleigh 27619 
Harvey E. Christensen. M.D.'" (GS) (704-322-9105) 

Box 1 1 IC, Fairgrove Church Rd., Conover 28613 



605 



Joseph L. DeWalt. M.D.-'= (IM) 

Iris Lane, Chapel Hill 27514 
James D. Hundley, M.D."» (ORS) (919-763-7344) 

2001 S. 17th St., Wilmington 28401 
A. Tyson Jennette, M.D.''" (ORSI (919-291-1300) 

Carolina Clinic. Wilson 27893 
Donald H. McQueen, III. M.D."-' (ORS) (919-277-0540) 

P.O. Box 667, Laurinburg 28352 
Joe M. McWhorter. M.D." (NS) (919-748-4020) 

Bowman Gray. Winston-Salem 27103 
Henry S. Miller. Jr., M.D.^^ (CD) (919-748-4467) 

Bowman Gray. Winston-Salem 27103 
Henry H. Nicholson. Jr.. M.D.''" (GS) (704-375-8956) 

1012 Kings Dr., Ste. 708. Charlotte 28283 
R. David Noel, M.D.^» (GS) (919-693-7066) 

1026 College St.. O.xford 27565 
Thomas L. Presson, M.D.^' (ORS) (919-275-0724) 

315 W. Wendover .Ave.. Greensboro 27408 
Donald B. Reibel. M.D."- (ORS) (919-781-5600) 

P.O. Box 10707, Raleigh 27605 
George D. Rovere. M.D." (ORS) (919-748-3946) 

300 S. Hawthorne Rd., Winston-Salem 27103 
Timothy N. Taft, M.D. 3- (ORS) (919-966-2030) 

UNC, Div. of Orth. Surg., Chapel Hill 27514 
Wayne B. Venters, M.D."' (ORS) (919-353-1413) 

200 Doctors Dr.. Ste. J, Jacksonville 28540 
John L. Wooten. M.D,'^ (ORS) (919-752-4613) 

6 Medical Pavilion, Greenville 27834 

Consultants: 

Al Proctor, Ph.D. (919-733-3822) 

Sports Medicine Div., N.C. Dept. of Public Instruction, 

Education Bldg, 114 W. Edenton St.. Raleigh 27611 
Mr. Raymond K. Rhodes (919-733-3821) 

School .Athletics & .Activities Div.. 

N.C. Dept. of Public Instruction. Education Bldg., 

114 W. Edenton St.. Raleigh 27611 

28. Advisors to North Carolina Association of Medical Assistants (6) 

Ernest H. Stines. M.D." (FP) Chairman (704-627-221 1 ) 

Midway Medical Ctr., Canton 28716 
Clinton L. Border. Jr.. M.D." (GS) (704-627-9677) 

P.O. Box 538, Jones Cove Rd., Waynesville 28786 
George M. Koseruba. M.D."'' (PD) (919-763-2476) 

1628 Doctors Circle, Wilmington 28401 
Robert E. Lane. M.D.^' (FP) (919-482-2116) 

Chowan Med. Ctr., Edenton 27932 
Walter N. Long. Jr., M.D.- (FP) (704-632-9736) 

107 Second Ave., SW, Taylorsville 28681 
Wayne B. Venters, M.D." (ORS) (919-3.53-1413) 

200 Doctor's Dr., Ste. J, Jacksonville 28540 

29. Committee on Medical Cost Containment II-3 (11) (1 Consultant) 

Jack B. Hobson, M.D."" (IM) Chainmin (704-374-1296) 

1351 Durwood Dr., Charlotte 28204 
Julian T. Brantley, M.D." (OBG) (919-273-4325) 

1409 Pembroke Rd.. Ste. 402. Greensboro 27408 
Charles A. Burkhart. Jr.. M.D." (919-761-1541) 

345 Westview Dr., SW, Winston-Salem 27104 
Charles L. Herring. M.D." (IM) (919-523-0026) 

310 Glenwood Ave., Kinston 28501 
Frederick L. Howell. M.D." (U) (919-765-4021) 

2932 Lyndhurst Ave., Winston-Salem 27103 
Jesse H. Meredith, M.D." (GS) (919-748-4278) 

Bowman Gray. Dept. of Surgery. Winston-Salem 27103 
David S. Nelson, M.D." (EM) (919-765-3950) 

248 Flintshire Rd., Winston-Salem 27104 



Charles A. Phillips. M.D."-' (GS) (919-295-5311) 

P.O. Box 4.30. Pmehurst 28374 
Joseph D. Russell, M.D."" (IM) (919-291-1300) 

Carolina Clinic. Wilson 27893 
Stuart M. Sessoms. M.D.''- (IM) (919-489-6779) 

P.O. Box 2291. Durham 27702 
Brian T. Sherrington. M.D."' (PD) (919-692-2444) 

Town Center Bldg., Southern Pines 28387 

Consultant: 

Wyatt E. Roye. Coordinator (919-832-9550) 
Voluntary Effort Prog., N.C. Hospital Association 
P.O. Box 10937. Raleigh 27605 



30. Committee on Medical Education III-7 (14) 

John D. Bridgers, Sr.. M.D." {PD) Chairman (919-882-4171) 

624 Quaker Lane, Ste. 200-A. High Point 27262 
Arthur C. Christakos, M.D.-'- (GYN) (DUKE) (919-684-2998) 

Duke Hospital. Box 3005. Durham 27710 
Eugene D. Furth, M.D.'-' (END) (ECU) (919-757-4633) 

ECU. Dept. of Med.. Greenville 27834 
Susan S. Gustke, M.D."- (IM) (919-733--5431) 

4100 Stranaver PI., Raleigh 27612 
William B. Hunt, Jr., M.D.-'' (PUD) (919-633-8620) 

P.O. Box 2157, New Bern 28560 
Charles M. Howell. M.D." (D) (919-748-4151) 

Bowman Gray, Winston-Salem 27103 
Eugene S. Mayer. M.D.-'= (GPM) (919-966-2461) 

UNC, Box 3, 221-H, AHEC Prog., Chapel Hill 27514 
Emery C. Miller. Jr.. M.D." (END) (BG) (919-748-4145) 

Bowman Gray. Winston-Salem 27103 
John W. Nance, M.D."- (FP) (NCAFP) (919-592-6011) 

403 Fairview St., Clinton 28328 
F. M. Simmons Patterson, M.D.'-" (GS) (ECU) (919-758-5200) 

ECU, P.O. Box 7224, Greenville 27834 
Charles R. Vernon. M.D.""' (?) (919-256-4106) 

7230 Wrightsville Ave.. Wilmington 28403 
Thomas A. Will, M.D.-" (GP) (704-922-3106) 

P.O. Box 515. Dallas 28034 
William B. Wood. M.D.-'= (PUD) (UNC) (919-933-2118) 

UNC, 231 MacNider Bldg.. Chapel Hill 27514 
Jerry C. Woodard. M.D."" (GE) (919-291-1300) 

Carolina Clinic. Wilson 27893 



31. Medical-Legal Committee V-6 (9) 

Julius Howell. M.D." (PS) Chairman (919-748-4171) 

Bowman Gray. Winston-Salem 27103 
George R. Clutts, M.D." (GS) (919-275-9554) 

344 N. Elm St.. Greensboro 27401 
Ira M. Hardy. II. M.D.'-i (NS) (919-752-5156) 

125 Moye Blvd.. Greenville 27834 
Amed L. Hinshaw. M.D.'- (OBG) (919-489-9482) 

1022 Homer St.. Durham 27707 
R. Page Hudson. Jr.. M.D.'= (FOP) (919-966-2253) 

Chief Med. Examiner's Office. Box 2488. Chapel Hill 27514 
Robert L. Rollins, Jr.. M.D."= (P) (919-733-2180) 

2500 Wake Dr.. Raleigh 27608 
Lary A. Schulhof. M.D." (NS) (704-255-7776) 

7 McDowell St., Asheville 28801 
Henry D. Severn. M.D." (ORS) (704-252-7331) 

111 Victoria at Oakland Rd.. Asheville 28801 
Andrew W. Walker, M.D."" (PS) (704-372-6846) 

2215 Randolph Rd., Charlotte 28207 



II 



i 



606 



Vol. 42, No. 8 



II 



32. Committee on Relationships between Medicine & Nursing II-7 (9) 

C. Glenn Pickard. Jr.. M.D.»= {\M) Chairimin (919-966-5650) 

N.C. Mem. Hospital. Chapel Hill 27514 
Joseph A. Berry. M.D." (IM) (919-534-1661) 

P.O. Box 176. Seaboard 27876 
Don C. Chaplin. M.D.' (IM) (919-227-3621) 

Kernodle Clinic. Burlington 27215 
E. Harvey Estes. Jr.. M.D.'- (CD) (919-684-5314) 

Duke Med. Ctr.. Box 2914. Durham 27710 
Daniel Gottovi. M.D.*^' (PUD) (919-763-8251) 

1202 Medical Ctr. Dr.. Wilmington 28401 
Louis T. Kermon. M.D."= (IM) (919-782-2333) 

Glenwood Prof. Village. Bldg. A. Raleigh 27608 
Eugene S. Mayer. M.D.^- (GPM) (919-966-2461) 

UNC. Box 3, 221-H. AHEC Prog.. Chapel Hill 27514 
Joyce H. Reynolds, M.D.»^ (EM) (919-768-2200) 

9550 Freeman Rd.. Kernersville 27284 
Eldora H. Terrell. M.D."" (IM) (919-889-1496) 

624 Quaker Lane. Ste. 211-B. High Point 27262 
Thad B. Wester. M.D."" (PD) (919-739-3318) 

103 W. 27th St.. Lumberton 28358 

33. Committee on .Vlembersliip 1-3 

John W. Foust. M.D."" (OT) Chairman (7(M-365-071 1 ) 
3535 Randolph Rd.. Charlotte 28222 

(THIS COMMITTEE TO BE APPOINTED) 

34. Committee on Mental Health VI-5 (23) (4 Consultants) 

Wilmer C. Belts. M.D."- (P) Chairman (919-782-01661 

3125 Glenwood Prof. Village. Raleigh 27608 
R. Jack Blackley, M.D."- (P) (919-733-7011) 

325 N. Salisbury St.. Raleigh 27611 
G. Norman Boyer. M.D.'' (P) (704-433-2514) 

Broughton Hosp.. Morganton 28655 
Theodore R. Clark. M.D." (P) (919-295-1231) 

P.O. Box 1569. Pinehurst 28374 
James F. Elliott. M.D.''" (P) (919-528-2433) 

John Umstead Hosp.. Butner 27509 
A. Ray Evans. M.D.'"" (P) (919-758-4810) 

1705 W. 6th St.. Bldg. H.. Greenville 27834 
Richard R. Felix. M.D." (P) (704-258-3880) 

.A-305 Doctor's Bldg.. Asheville 28801 
William M. Fowlkes. Jr.. M.D." (P) (919-851-8888) 

1209 Glendale Ave.. Raleigh 27612 
Robert W. Gibson. M.D." (P) (919-768-6930) 

190 Charlois Blvd.. Winston-Salem 27103 
Barbara M. Jordan. M.D."" (P) (919-738-5261) 

P.O. Box 552. Lumberton 28358 
Charles E. Llewellyn. Jr.. M.D.^- (P) (919-684-3332) 

Duke Med. Ctr.. Box 3173. Durham 27710 
Hans Lowenbach. M.D.'- (P) (919-544-2450) 

Rt. 3. Box 273. Durham 27713 
J. Gray McAllister. III. M.D.'^- (P) (919-968-4651) 

P.O. Box 864. Chapel Hill 27514 
Harry H. McLean. III. M.D.'^ (FP) (919-757-6841) 

ECU. Student Health Ctr.. Greenville 27834 
Mary Margaret McLeod. M.D.'-' (PD) (919-775-3232) 

Drawer 1047. Sanford 27330 
J. Douglas McRee. M.D.-- (P) (919-733-6520) 

Dorothea Dix Hosp.. Raleigh 27611 
Philip G. Nelson, M.D." (P) (919-758-3145) 

Medical Pavilion, Ste. 9. Greenville 27834 
James W. Osberg. M.D.^^ (P) (919-787-7389) 

8804 Katharina Crt.. Raleigh 27612 
Barry S. Ostrow. M.D."- (P) (919-733-5241) 

Dorothea Dix Hospital. Raleigh 27611 
Ray G. Silverthome. M.D." (OBG) (919-946-4101) 

408 E. 12th St.. Washington 27889 

August 1981. NCMJ 



Nicholas E. Stratas, M.D.'^ (P) (919-787-7125) 
3900 Browning PI., Ste. 201, Raleigh 27609 

Charles R. Vernon, M.D."' (P) (919-256-4106) 
7230 Wrightsville Ave.. Wilmington 28403 

N. P. Zarzar. M.D.''- (P) (919-782-0166) 
3125 Glenwood Prof. Village. Bldg. H. Raleigh 27608 

Consultants: 

Paul T. Kayye. M.D. (919-832-0581) 

Dept. of Corrections. Polk Youth Center, 

1831 Blue Ridge Rd.. Raleigh 27607 
Mrs. H. William Tracy (Marguerite) (Auxiliary) (704-375-6386) 

138 Cherokee PI.. Unit 9. Charlotte 28207 
Mrs. Wymene Valand (919-833-6076) 

706 Woodburn Rd., Raleigh 27605 
Richard H. Williams, Ph.D. (919-756-5346) 

111 Cardinal Dr., Greenville 27834 

35. Committee on Nominations (10) (3-yr term) 

Gloria F. Graham. M.D."" (D) (4th) (1982) Chairman 

(919-291-.';600) 702 Broad St.. Wilson 27893 
W. Otis Duck. M.D.'" (FP) (10th) (1984) (704-689-2581) 

Drawer F. Mars Hill 28754 
James D. Hundley. M.D."' (ORS) (3rd) (1983) (919-763-7344) 

2001 S. 17th St.. Wilmington 28401 
Robert E. Miller. M.D."" (ORS) (7th) (1983) (704-373-0544) 

1822 Brunswick Ave.. Charlotte 28207 
William H. Romm. M.D.'" (FP) (1st) (1982) (919-435-6621) 

P.O. Box 10, Moyock 27958 
James M. Ross. M.D.'" (FP) (9th) (1983) (704-459-7324) 

P.O. Box 490. Claremont 28610 
J. Larry Simpson, M.D.'" (FP) (8th) (1982) (919-625-1360) 

132-A W. Miller St., Asheboro 27203 
Robert G. Townsend. Jr., M.D.-*" (FP) (5th) (1983) 

(919-875-5101) P.O. Box 666. Raeford 28376 
J. B. Warren. M.D.-' (FP) (2nd) (1984) (919-637-6193) 

P.O. Box 1465, New Bern 28560 
John W. Watson. M.D.'" (FP) (6th) (1984) (919-693-8126) 

104 New College St., Oxford 27565 

36. Committee on Occupational & Environmental Health VI-6 (15) 
(3 Consultants) 

Austin T. Hyde. Jr., M.D."' (A) Chairman (704-286-9036) 

P.O. Box 970. Rutherfordton 28139 
Julian S. Albergotti. Jr.. M.D."" (OM) (704-378-7320) 

P.O. Box 30188. Charlotte 28230 
Robert M. Caldwell, M.D.»" (PH) (919-789-9571) 

P.O. Box 1267. Mt. Airy 27030 
Jerry Cassuto. M.D.^' (OM) (919-697-6220) 

P.O. Box 25000. Greensboro 27420 
John M. Dubose, M.D.'^ (TS) (919-522-1626) 

P.O. Box 1316, Kinston 28501 
Charles P. Ford, Jr., M.D.'-" (OM) (919-354-3018) 

Rt. 1. Box 885-M. Morehead City 28557 
Austin P. Fortney. M.D.-" (IM) (919-454-2122) 

P.O. Box 579. Jamestown 27282 
Daniel Gottovi. M.D."' (PUD) (919-763-8251) 

1202 Medical Center Dr., Wilmington 28401 
Charles G. Gunn. Jr.. M.D.'^ (OM) (919-744-3708) 

Hanes Corp., P.O. Box 5416, Winston-Salem 27103 
T. Tilghman Herring. M.D."" (OM) (919-291-7001) 

Wilson Clinic, Wilson 27893 
Gregory G. Holthusen. M.D." (ORS) (919-768-1270) 

1425 Plaza Dr.. Winston-Salem 27103 
Harold R. Imbus. M.D.-" (OM) (919-379-2443) 

Buriington Ind., P.O. Box 21207. Greensboro 27420 
Ted R. Kunstling. M.D."- (PUD) (919-872-4850) 

1212 Cedarhurst Dr.. Raleigh 27609 



607 



Robert E. Lane. M.D.-' (FP) (919-482-2116) 

Chowan Med. Ctr., Edenton 27932 
Charles F. Martin. M.D.^' (OM) (919-379-6%5) 

1201 Maple St., Greensboro 27405 

Consultants: 

Mr. Dan Baucom (919-733-3680) 

Div. of Health Serv.. P.O. Box 2091. Raleigh 27602 
David A. Fraser. Sc.D. (919-966-4152) 

UNC School of Public Health. Chapel Hill 27514 
Bernard Greenberg. Ph.D. (919-966-4152) 

UNC School of Public Health. Rosenau Hall. 201-H. 

Chapel Hill 27514 

37. Committee on Study of Operative Deaths II-5 (11) 

Albert A. Bechtoldt. Jr.. M.D.-'= (AN) Chciirman 

(919-966-5136) 

UNC, Dept. of Anes.. Chapel Hill 27514 
Benjamin F. Fortune. M.D.-" (AN) (919-272-7755) 

906 W. Comwallis Dr.. Greensboro 27408 
Charles L. Garrett. Jr., M.D." (PTH) (919-353-3498) 

P.O. Box 1358, Jacksonville 28540 
Charles T. Harris, Jr., M.D.*"' (AN) (704-371-4049) 

401 Fesbrook Crt.. Charlotte 2821 1 
Glen E. Hawkins. M.D.''-' (AN) (919-776-0241) 

106 Hillcrest St., Sanford 27330 
John R. Hoskins, III, M.D." (AN) (704-254-1969) 

202 Doctor's BIdg.. Asheville 28801 
R. Page Hudson, Jr., M.D. 3- (FOP) (919-966-2253) 

Chief Med. Examiner's Office. P.O. Box 2488, 

Chapel Hill 27514 
Stephen H. Mazur, M.D."" (AN) (919-731-6068) 

504 Walnut Creek Dr., Goldsboro 27530 
Ross S. McElwee, Jr.. M.D.''" (GS) (704-364-8100) 

3535 Randolph Rd.. Charlotte 28211 
Richard T. Myers, M.D.-'^i (GS) (919-748-4541) 

Bowman Gray, Winston-Salem 27103 
H. Ryland Vest, Jr., M.D.''^ (AN) (919-781-7420) 

2800 Blue Ridge Blvd.. Raleigh 27607 

38. Committee on Personnel & Headquarters Operation 1-4 (6) 
(10 Ex Officio) 

Shahane R. Taylor. Jr., M.D.^' [OPH) C/uiinmiii 

(919-274-4626) 

348 N. Elm St.. Greensboro 27401 
Thornton R. Cleek. M.D.™ (FP) (919-629-2387) 

379 S. Cox St.. Asheboro 27203 
Gloria F. Graham. M.D."" (D) (919-291-5600) 

702 Broad St.. Wilson 27893 
Elizabeth P. Kanof, M.D."= (D) (919-833-3672) 

1300 St. Mary's St.. Raleigh 27605 
Robert H. Shackelford. M.D."'' (FP) (919-658-4954) 

238 Smith Chapel Rd.. Mt. Olive 28365 
Ernest B. Spangler. M.D.^' (R) (919-855-8972) 

Drawer X-3. Greensboro 27402 

Ex Officio: 

Josephine E. Newell. M.D."" (FP) (President) (919-833-3836) 

Raleigh Townes, Apt. 47, 525 Wade Ave., Raleigh 27605 
Marshall S. Redding. M.D.'" (OPH) (President-Elect) 

(919-335-5446) 

1142 N. Road St., Elizabeth City 27909 
Frank Sohmer, M.D." (GE) (Past-President) (919-72.'!-8326) 

2240 Cloverdale Ave.. Ste. 88. Winston-Salem 27103 
Jack Hughes. M.D. 3- (U) (Secretary) (919-286-1297) 

923 Broad St.. Durham 27705 
Thomas B. Dameron. Jr.. M.D."" (ORS) (9 19-781 -.5600) 

P.O. Box 10707, Raleigh 27605 



F. Maxton Mauney. Jr.. M.D." (CDS) (704-258-1121) 

257 McDowell St.. Asheville 28803 
Gloria F. Graham. M.D."» (D) (9I9-291-.';600) 

702 Broad St.. Wilson 27893 
Charles A. Hoffman, Jr.. M.D."" (U) (919-485-8801) 

513 Owen Dr., Fayetteville 28304 
John L. McCain. M.D."" (RHU) (919-291-7001) 

Wilson Clinic. Wilson 27893 
Rose Pully. M.D." (FP) (919-523-2569) 

318 College St.. Kinston 28501 

39. Committee on Physicians' Health & Effectiveness VI-7 (22) 

(2 Consultants) 

Theodore R. Clark. M.D."' (P) Clwinnan (919-295-1231) 

P.O. Box 1569. Pinehurst 28374 
Irvin L. Blose, M.D." (P) (919-758-6812) 

ECU, Dept. of Psy. Med.. Greenville 27834 
Frederick A. Blount. M.D.^^ (PD) (919-748-4356) 

PA Program. 1990 Beach St.. Winston-Salem 27103 
Martin L. Brooks. M.D."* (GP) (919-521-4421) 

P.O. Box 37. Pembroke 28372 
Stanley S. Burns. Jr.. M.D."" (OTO) (704-372-3300) 

1600 E. Third Ave.. Charlotte 28204 
A. Eugene Douglas. Jr.. M.D.'" (P) (919-738-8230) 

P.O. Box 552, Lumberton 28358 
Robert F. Eaton, M.D.^^ (ORS) (704-692-5781) 

501 6th Ave.. Hendersonville 28739 
John A. Ewing. M.D.^- (P) (919-966-4551) 

N.C. Mem. Hospital. Chapel Hill 27514 
Robert W. Gibson. Jr.. M.D.'^ (P) (919-768-6930) 

190 Charlois Blvd.. Winston-Salem 27103 
Harold R. Gollberg. M.D." (PN) (7O4-258-3.'i00) 

73 W. Kensington Rd.. Asheville 28804 
Riley M. Jordan. M.D.<" (FP) (919-875-5151) 

116 Campus Ave., Raeford 28376 
Donald E. Macdonald. M.D."" (P) (704-2.58-3500) 

3.'56 Biltmore Ave.. Asheville 28801 
Charles T. Medlin. M.D."- (FP) (919-772-.3266) 

P.O. Box 128. Garner 27529 
Jack E. Mohr, M.D.=- (OBG) (919-967-1441) 

706 Wellington Dr.. Chapel Hill 27514 
Philip G. NeLson. UH.'* (P) (919-758-3145) 

Medical Pavilion. Ste. 9. Greenville 27834 
James W. Osberg. M.D."- (P) (919-787-7389) 

8804 Katharina Crt.. Raleigh 27612 
William J. Reid, M.D.-" (FP) (919-274-6171) 

2301 Danbury Rd.. Greensboro 27408 
Christian F. Siewers. M.D.-" (ORS) (919-323-6770) 

Southeastern Reg. Rehab. Ctr. . Box 2000. Fayetteville 28302 
J. David Stratton. M.D."" (OPH) (704-364-8576) 

3535 Randolph Rd.. R-202. Charlotte 28211 
Rex R. Taggart. M.D."" (FP) (704-554-8373) 

4900 Torrey Pines Crt.. Charlotte 2821 1 
Charles R. Vernon. M.D."' (P) (919-2.'i6-4106) 

7230 Wrightsville Ave.. Wilmington 28403 
Robert E. Williford, M.D." (FP) (919-625-4000) 

208 Foust Ave.. Asheboro 27203 

Consultants: 

Mrs. Hampton Hubbard (Anne) (Auxiliary President) 

(919-592-7885) 

102 Country Club Circle. Clinton 28328 
Mrs. John L. McCain (Betty) (Auxiliary) (919-243-4248) 

11.34 Woodland Dr.. Wilson 27893 

40. Medical Society Consultant on Podiatry (1) 

Robert B. Nelson. M.D.»- (ORS) (919-781-5600) 
P.O. Box 10707, Raleigh 27605 



608 



Vol. 42, No. 8 



i 



41. Committee on Professional Insurance 1-5 (24) 

Julius A. Green. Jr.. M.D.''- (K) Chairman (919-787-8221) 

P.O. Box 19366. Raleigh 27609 
Richard H. Ames. M.D."" (NS» (919-373-0762) 

1409 Pembroke Road. Ste. 406. Greensboro 27408 
John H. Baker. M.D.''= (OBGl (919-876-8225) 

4914 Quail Hollow Dr.. Raleigh 27609 
Thad J. Barringer. M.D."- (P) (919-787-712.'!) 

3900 Browning PI., Ste. 201. Raleigh 27609 
H. Robert Brashear. Jr.. M.D.^- (919-966-2030) 

N.C. Memorial Hospital. Chapel Hill 27514 
F. Payne Dale. M.D.'^ (GS) (919-522-1626) 

Kinston Clinic. N.. Box 1316. Kinston 28501 
Courtland H. Davis, Jr.. M.D.^^ (NS) (919-748-4083) 

Bowman Gray. Winston-Salem 27103 
William W. Farley. M.D.''- (PD) (919-782-8.326) 

3821 Merton Dr.. Raleigh 27609 
Charles L. Garrett, Jr.. M.D." (PTH) (919-3.53-3498) 

P.O. Box 13.'58, Jacksonville 28.540 
W. Blake Garside. M.D." (PS) (919-872-2616) 

1112 Dresser Crt.. Raleigh 27609 
Lewis J. Gaskin. M.D."- (AN) (919-781-7420) 

Rex Hosp., Dept. Anes.. Raleigh 27607 
Charles M. Hassell, Jr., M.D." (PTH) (919-379-4074) 

1200 N. Elm St., Greensboro 27420 
David H. Jones. M.D."= (OPH) (919-787-2758) 

3900 Browning PI.. Raleigh 27609 
T. Russell Kitchens. M.D.-" (PS) (919-373-0566) 

41 1-H Parkway St.. Greensboro 27401 
Donald T. Lucey, M.D.»= (U) (919-876-432.'5) 

P.O. Box 17908. Raleigh 27619 
William B. McCutcheon. Jr.. M.D." (TS) (919 383-5531) 

1830 Hillandale Rd., Durham 27705 
Willis E. Mease. M.D.'^' (FP) (919-324-3105) 

P.O. Box 97, Richlands 28574 
Kenneth A. Podger, M.D." (GYN) 

7701 Beach Dr.. Myrtle Beach. SC 29577 
Frank Sabiston, Jr., M.D.''-' (GS) (919-522-1626) 

P.O. Box 1316, Kinston 28501 
William J. Senter, M.D.''- (IM) (919-832-5125) 

704 W. Jones St.. Raleigh 27603 
Nathaniel L. Sparrow, M.D."- (OTO) (919-787-7171) 

P.O. Box 18946, Raleigh 27619 
Robert T. Stone, M.D."" (OTO) (919-291-7001) 

1704 S. Tarboro St., Wilson 27893 
Nicholas E. Stratas. M.D.""- (P) (919-787-7125) 

3900 Browning Pi.. Ste. 201, Raleigh 27609 
Robert J. Sullivan, Jr.. M.D.-" (IM) (919-684-6721) 

294 Highview Dr., Chapel Hill 27514 
i i 

42. Committee on Rehabilitation Medicine rV-5 (15) 

Robert E. Miller. M.D.'^" (ORS) Chairman (704-373-0544) 

1822 Brunswick Ave., Charlotte 28207 
Ronald C. Demas. M.D.''" (N) (704-372-3714) 

225 Hawthorne Lane. Ste. 501, Charlotte 28204 
Frank W. Clippinger. Jr.. M.D." (ORS) (919-684-4229) 

Duke Med. Ctr,, Box 3935. Durham 27710 
Carl J. Hiller, M,D.-' (ORS) (919-633-32.%) 

P.O. Drawer 1694, New Bern 28560 
David L. Jarrett, M.D." (ORS) (704-274-2236) 

9 All Souls Crescent, Asheville 28803 
Charles E. Llewellyn, Jr., M.D." (P) (919-684-3332) 

Duke Med. Ctr.. Box 3173, Durham 27710 
Edwin H. Martinat. M.D.-" (ORS) (919-773-3782) 

3333 Silas Creek Parkway, Winston-Salem 27103 
Henry S. Miller. Jr.. M.D.-" (CD) (919-748-4467) 

Bowman Gray, Winston-Salem 27103 



William P. Parker. M.D.'^-'^ (NS) (919-762-1804) 

1301 Cypress Grove Dr., Wilmington 28401 
Suzanne V. H. Sauter, M.D." (RHU) (919-966-4191) 

109 Mimosa Dr.. Rt. 2. Chapel Hill 27514 
Christian F. Siewers, M.D.-'' (ORS) (919-323-6770) 

Southeastern Reg. Rehab. Ctr. . Box 2000. Fayetteville 28302 
Robert L. Timmons. M.D."^ (NS) (919-752-5156) 

125 Moye Blvd.. Greenville 27834 
William C. Trier. M.D." (PS) (919-966-4446) 

UNC. Div. of Plastic Surg.. Chapel Hill 27514 
Michael D. Weaver, M.D." (DR) (919-756-7923) 

1711 W. Sixth St., Greenville 27834 
Donald D. Weir, M.D." (IM) (919-757-4345) 

Regional Rehab. Ctr., Box 8028, Greenville 27834 

43. Retirement Savings Plan Committee 1-6 (7) (3-yr term) 
W. Lester Brooks, Jr., M.D.''" (IM) (1983) Chairman 

(704-333-4175) 1851 E. Third St.. Chariotte 28204 
Jesse Caldwell, M.D.^'^ (GYN) (1984) (704-865-0968) 

1307 Park Ln.. Gastonia 28052 
Thomas M, Daniel. M.D.'" (PD) (1982) (919-934-7123) 

P.O. Box 568. Smithfield 27577 
William F. Hollister, M.D,''^ (GS) (1984) (919-692-2677) 

Drawer 149, Southern Pines 28387 
George W. James, M.D," (D) (1983) (919-772-6155) 

205 S. Hawthorne Rd., Winston-Salem 27103 
Henry D, Jordan, M.D."-' (PTH) (1984) (919-343-7074) 

Box 9000, Wilmington 28402 
Cari S. Phipps, M.D." (END) (1982) (919-765-1640) 

2933 Maplewood Ave., Winston-Salem 27103 

44. Committee on Social Services Programs (Including Medicaid) 
IV-6 (15) (2 Consultants) 

Joseph D. Russell, M.D."" (IM) Chairman (919-291-1300) 

Carolina Clinic, Wilson 27893 
Elwood B. Coley. M.D." (PD) (919-739-3318) 

103 W. 27th St., Lumberton 28358 
Suzanne W. Fletcher. M.D." (IM) (919-966-4205) 

UNC Dept. Med.. Chapel Hill 27514 
Richard W. Furman, M.D."' (TS) (704-264-2340) 

State Farm Road. Boone 28607 
Charles L. Garrett. Jr., M.D.''" (PTH) (919-353-3498) 

P.O. Box 13.58. Jacksonville 28540 
Hector H. Henry, II. M.D.'-' (U) (704-786-5133) 

102 Lake Concord Rd., NE. Concord 28025 
Edna M. Hoffman, M.D.^'' (919-485-8801) 

348 Valley Road, Fayetteville 28305 
Ronald H. Levine, M.D."- (PH) (919-782-0838) 

2404 White Oak Road, Raleigh 27609 
Charles R. Martin, M.D."' (PD) (919-353-0581) 

120 Memorial Dr., Jacksonville 28540 
Campbell W. McMillan, M.D." (PHO) (919-966-3133) 

N.C. Memorial Hosp., Chapel Hill 27514 
James S. Mitchener, Jr.. M.D.'*' (GS) (919-276-3541) 

P,0. Box 1808, Laurinburg 28352 
Sarah T, Morrow, M.D." (PH) (919-733-4534) 

Dept. HR, 325 N, Salisbury St., Raleigh 27611 
Emery L. Rann. M.D.«" (FP) (704-333-0721) 

1001 Beatties Ford Rd., Charlotte 28216 
Samuel E. Scott, M.D.' (FP) (919-421-3221) 

Rt. 2. Buriington 27215 
Nelson B. Watts, M.D," (END) (704-254-0771) 

93 Victoria Rd., Asheville 28801 

Consultants: 

Barbara D. Matula, Director (919-733-2060) 

Divn. Medical Assistance, 336 Fayetteville St. Mall, 
Raleigh 27602 



August 1981, NCMJ 



609 



Lillian J. Todd, RN. Nursing Consultant (919-733-6775) 
Divn. Medical Assistance. 336 Fayetteville St. Mall, 
Raleigh 27602 

45. Committee on Tramc Safety II-6 (8) (4 Consultants) 

George Johnson. Jr.. M.D.'- (GS) Chairman (919-966-3391) 

N.C. Mem. Hospital. Chapel Hill 27.'il4 
Gerald L. Ellison. M.D." (DR) (919-323-6186) 

49.S Rayconda. Fayetteville 28304 
Joe M. McWhorter. M.D.'" (NS) (919-748-4020) 

Bowman Gray. Winston-Salem 27103 
David S. Nelson. M.D." (EM) (919-76.<i-3950) 

248 Flintshire Rd.. Winston-Salem 27104 
Fred G. Patterson. M.D.'- (FP) (919-968-4551) 

1001 S. Hamilton Rd.. Chapel Hill 27514 
John O. Reynolds. Jr., M.D."" (OPH) (704-637-0158) 

310 N. Main St.. Salisbury 28144 
Joseph D. Russell, M.D.»» (IM) (919-291-1300) 

Carolina Clinic, Inc., Wilson 27893 
Robert L. Timmons, M.D." (NS) (919-752-5156) 

125 Moye Blvd.. Greenville 27834 

Consultants: 

Judge Hamilton H. Hobgood (919-496-3891) 

205 John St.. Louisburg 27549 
Mr. Grover McKay (919-733-3493) 

Medical Evaluation Coordinator 

Divn. ot'Motor Vehicles. 1 100 New Bern Ave.. Raleigh 2761 1 
Myron Wolbarsht. Ph.D. (919-684-2032) 

Duke Medical Ctr.. Dept. Oph., Durham 27710 
Mr. Douglas Wooten, (919-733-3222) 

Highway Safety Branch, Epidemiology Section, 

Divn. of Health Services. P.O. Box 2091, Raleigh 27602 

46. ad hoc Committee to Delineate the Administrative Code for the 
North Carolina Medical Society 1-7 (5) 

E. Thomas Marshburn. Jr.. M.D.'''' (IM) Chairman 

(919-762-9621) 

3208 Oleander Dr.. Wilmington 28401 
Thomas B. Dameron. Jr.. M.D."- (ORS) (919-781-5600) 

P.O. Bo.x 10707. Raleigh 27605 
Jack B. Hobson. M.D.«" (IM) (704-374-1296) 

1351 Durwood Dr.. Charlotte 28204 



Jack Hughes. M.D.-'= (U) (919-286-1297) 

923 Broad St.. Durham 27705 
Marshall S. Redding. M.D.'" (OPH) (919-33-'5-.M46) 

1142 N. Road St., Elizabeth City 27909 



47. ad hoc Committee to Assess the Legal Services and Legal Needs of 
the North Carolina Medical Society (5) 

Jesse Caldwell. Jr.. M.D.''" i.G\N) Chairman (704-865-0968) 

1307 Park Lane. Gastonia 28052 
H. David Bruton. M.D.«' (PD) (919-692-2444) 

Town Center. Southern Pines 28387 
F. Maxton Mauney. Jr.. M.D." (CDS) (704-258-1 121) 

2.57 McDowell St.. Asheville 28803 
Eugene S. Mayer. M.D.'- (GPM) (919-966-2461) 

UNC. Box 3, 221-H, Chapel Hill 27514 
Edwin W. Monroe, M.D." (IM) (919-757-4606) 

ECU Sch. of Medicine. Greenville 27834 



48. Committee to Investigate Grievances Relative to Medical Care of 
Prison Residents VT-8 (8) (I Consultant) 

Jesse Caldwell. Jr.. M.D.-'" (GYN) Chairman (704-865-0968) 

1307 Park Lane. Gastonia 28052 
George C. Debnam, M.D."- (GP) (919-832-1667) 

524 S. Blount St.. Raleigh 27601 
John A. Ewmg. M.D.'- (P) (919-966-4,551) 

N.C. Memorial Hospital. Chapel Hill 27514 
George G. Gilbert. M.D." (V) (704-253-5314) 

I Dr's Park. Asheville 28803 
Susan S. Gustke. M.D."- (IM) (919-733-5431) 

4100 Stranaver PI.. Raleigh 27612 
Philip G. Nelson. M.D." (P) (919-758-3145) 

Medical Pavilion. Ste 9. Greenville 27834 
Rose Pully. M.D.-"' (FP) (919-523-2569) 

318 College St., Kinston 28501 
William B. Wood, M.D.'- (PUD) (919-933-2118) 

UNC. 231 MacNider Bldg.. Chapel Hill 27514 

Consultant: 

Rep. Wilma C. Woodard (919-772-2339) 
1528 Glen Eagle Dr.. Garner 27529 



JOINT PRACTICE COMMITTEE 

OF THE 

NORTH CAROLINA MEDICAL SOCIETY 

AND THE 

NORTH CAROLINA NURSES" ASSOCIATION 

(3-yr term) 



Hettie Garland. RN (1984) Chairman 

MAHEC. 501 Biltmore Ave.. Asheville 28801 

(704-258-0881) 
Louis T. Kermon. M.D. (IM) (1982) Vice-Chairman 

Glenwood Prof. Village. Bldg. A. Raleigh 27608 

(919-782-2333) 
Joseph A. Berry. M.D. (IM) (1984) 

P.O. Box 176. Seaboard 27876 

(919-534-1661) 
E. Harvey Estes. Jr.. M.D. (CD) (1984) 

Duke Med. Ctr.. Box 2914. Durham 27710 

(919-684-5314) 
Daniel Gottovi. M.D. (PUD) (1984) 

1202 Medical Ctr. Dr.. Wilmington 28401 

(919-763-8251) 



Eugene S. Mayer. M.D. (GPM) (1983) 

UNC. Box 3. 221-H. Chapel Hill 27514 

(919-966-2461) 
C. Glenn Pickard. Jr.. M.D. (IM) (1982) 

N.C. Memorial Hospital, Chapel Hill 27514 

(919-%6-5650) 
Joyce H. Reynolds, M.D. (EM) (1982) 

9550 Freeman Rd.. Kernersville 27284 

(919-768-2200) 
Eldora J. Terrell. M.D. (IM) (1983) 

624 Quaker Lane. Ste. 211-B. High Point 27262 

(919-889-1496) 
Thad B. Wester. M.D. (PD) (1983) 

103 W. 27th St.. Lumberton 28358 

(919-739-3318) 



610 



Vol. 42, No. 8 



Audrey Booth, RN (1984) '■ 

5305 Beaumont Dr., Durham 27707 ■> 

( ) 

Wanda Boyette. RN (1984) 

Asst. Administrator/Nursing 

Sampson Co. Mem. Hospital, Clinton 28328 

(919-592-8511) 
Janet Campbell, RN, Ph.D. (1984) 

Rt. 8, Box 206. Raleigh 27612 

(919-787-9300) 
Allene Cooley, RN (1984) 

2501 Greenbrier Rd., Winston-Salem 27104 

(919-725-3748) 
Kerry Dominick, RN (1984) 

1925 #305 Sharon Rd., W., Charlotte 28210 

(704-554-0232) 
Eloise R. Lewis, RN, Ed.D. (1982) 

Dean, School of Nursing, UNC-G, 

Greensboro 27412 

(919-379-5177) , s .- 



Audrey Rogers, RN (1984) 

2462 Boxwood Dr., Chapel Hill 27514 
Evelyn Schaffer. RN (1984) 

5 Hampton Rd., Salisbury 28144 

(919-633-0411) 



EX OFFICIO: 

Josephine E. Newell. M.D., President 
North Carolina Medical Society 
Raleigh Townes, Apt. 47, 525 Wade Ave., 
Raleigh 27605 
(919-833-3836) 

Marshall S, Redding, M.D., President-Elect 
North Carolina Medical Society 
1142 N. Road St., Elizabeth City 27909 
(919-335-.5446) 

Ernestine Small, RN, President 

North Carolina Nurses' Association 
P.O. Box 20106, Greensboro 27420 
(919-379-5010) 



August 1981, NCMJ 



611 



NORTH CAROLINA MEDICAL SOCIETY 
APPROVED INSURANCE PROGRAMS 

Major Hospital and Nurse Expense Insurance 

$25,000 maximum benefit: choice of deductibles from $100to $1,000: benefits 
paid regardless of other insurance 

In Hospital Indemnity Insurance 

Benefits available from $30 to $75 per day: pays regardless of other insurance 

Excess Major Medical Insurance 

$250,000 maximum: choice of $15,000 or $25,000 deductible 

Term Life Insurance 

Coverage from $10,000 to $100,000: dependents and employees eligible 

Business Overhead Expense Insurance 

Monthly benefits from $200 to $3,000 per month: benefits payable after 31 days 
of disability retroactive to the first day of disability: benefits payable up to 12 
consecutive months: premiums are tax deductible as a business expense 

Each of the above plans may qualify for use by professional corporations. 

We have been working with physicians in North Carolina for more than 40 
years. ' ; 



WRITE OR CALL FOR FURTHER INFORMATION 

GOLDEN-BRABHAM INSURANCE AGENCY, INC. 

108 East Northwood St., P.O. Drawer 6395 

Across Street from Cone Hospital 

Greensboro, N.C. 27405 

Tel: (919) 2753400 or 275-5035 



Classified Ads 



INVESTMENTS: Laboratory Certificated Investment Diamonds: for 
capital preservation and inflation protection. Our Diamonds fea- 
ture GIA Certificates, G-emprints and direct from the diamond 
cutter prices. For complete information and a free Diamond Guide 
write today. J. Morant (Laboratory Certificated Diamonds), 1434 
Argonne Blvd., Winston-Salem, NC 27107. 

BOARD CERTIFIED PSYCHIATRIST, Extensive Clinical 
Experience. Prefer Community Program, but would con- 
sider other quality clinical opportunity. Contact: Andrew S. 
Wachtel, M.D., P.O. Box 23, Spencer, WV 25276. Phone: 
927-2110. 

MEDICAL CLINIC FACILITY FOR SALE: Walking distance 
Charlotte Memorial Hospital, group of four Buildings, 14,000 sq. 
ft., 72 parking spaces. For Information call Bissell McKee, Inc., 
704-375-1137 or write P.O. Box 34753, Charlotte, NC 28234. 

FAMILY PHYSICIAN WANTED: To join an estabUshed family 
practice in a small town. Several years of family practice experience 
or equivalent is required. Salary $1,000 weekly. Reply to Employ- 
ment Security Commission, 111 East Third Street, Gastonia, NC 
28052 or to the nearest Employment Security Commission. Please 
quote order number 673143. 

Matching communities-seeking-physicians with physicians-in-train- 
ing requiring tuition assistance. Write for more info to: Tuition 
Assistance Program, Inc., P.O. Box 6221, Duluth, MN 55806. 

LOCUM TENENS PHYSICIAN AVAILABLE: N.C. only Family 
Practice & E.R., American Trained, 3 years FP Residency, 6 years 
FP experience. Office, Hospital, ER, nursing home. Charge $40 per 
hour, min. 8 hr. day working. Max 5 davs — 40c per mile traveling. 
Contact: Thomas White, M.D., Box 3403, Kinston, NC 28501 — 
Home 919-523-6106, Office 919-522-7904. 

FOR SALE: Packard Tricarb (series 3375E) refrigerated liquid 
scintillation counter with 200 sample capacity and Texas 
Instruments Electronic Data Terminal Printer (model 700). 
Call 919-471-1891 or 919-544-4019 for details. 

FOR SALE: John Deere 400 hydrostatic tractor, mower and 
tiller. 175 hours of use on tractor. Call 919-471-1891 or 
919-544-4019 for details. 

FOR SALE: Scientific counter-cabinet units. Center and wall units 
available. Drawers are on rollers, doors have hidden hinges and all 
edges are banded. All sinks are stainless steel and are provided with 
a distilled water outlet. Electrical recepticles are attached to 
counter tops. Interfacing glassware washer and fume hood are 
available. Call 919-471-1891 or 919-544-4019 for details. 

FOR SALE: Medical Clinic in northern Durham County. 3400 sq. ft. 
located on 2 acres. Large laboratory with safety equipment. Call 
919-471-1891 or 919-544-4019 for details. 



FOR SALE: Ranch style home in northern Durham County 
adjacent to above medical clinic. 3100 sq. ft. located on 
8 acres. Horse stable with tack rooms. Pasture is fenced. 
Call 919-471-1891 or 919-544-4019 for details. 

IBM MAG Card Systems, Typewriters, Selectrics and Electronic. All 
units are factory reconditioned and warranted. Call (919) 782-4989 
for special pricing. Advanced Components Co., P.O. Box 17201, 
Raleigh, N.C. 27619. 

FOR SALE: Condominium, Hilton Head, S.C., Palmetto Dunes, 3 
bedrooms, 3 baths. BeautifuUy furnished. CaU (919) 722-1534. 

COMPHEALTH — Locum Tenens — Physicians covering physi- 
cians, nationwide, all specialties. We provide cost effective quality 
care. CaU us day or night. T. C. Kolff, M.D., President, Comp- 
Health, 175 W. 200 S., Salt Lake City, Utah 84101 , (801 ) 532-1200. 

TEXAS — IMMEDIATE OPENINGS in DaUas for Ophthalmologist, 
ENT, and Perinatologist: General Practitioners needed in Austin. 
Also excellent openings for Family Practitioners, Internists, Or- 
thopaedic Surgeons, OB/G YN, Pedis, and Neurologist in cities with 
5,000-65,000 population near mctroplex areas. Write Texas Doc- 
tors Group, Box 177, Austin, Texas 78767, (512) 476-7129. 

EDENTON — Immediate opening for recent graduate in F.P. 
Guaranteed income plus bonus & fringe benefits. Need locum 
tenens July and August. D. O. Wright, M.D. (919) 482-2116. 

PHYSICIAN ASSISTANTS — Would a Physician Assistant be of 
benefit to your practice? The North Carolina Academy of Physi- 
cians' Assistants responds promptly to physician inquiries. Con- 
tact: Paul C. Hendrix, P.A.-C, Chairman, Employment Commit- 
tee, 708 Duluth Street, Durham, North Carolina 27705. Telephone: 
(919) 684-6101. 

NORTH CAROLINA — Family Practice/Emergency Medicine. 
Unique opportunity, immediate partnership available. Rapidly 
growing practice. Small hospital, rural area, two hours to Atlantic 
beaches. Starting from $55,000 to $60,000 guaranteed. Unlimited 
growth — excellent benefit package. Call or write about this excel- 
lent opportunity: Community Physicians, Inc. 113 Landmark 
Square, Virginia Beach, Virginia 23452 (8*4) 486-0844. 

VIRGINIA — Unique opportunity. Emergency Medicine. Modern 
service. Immediate or delayed openings for career-oriented physi- 
cians, unlimited potential. Guaranteed income of $55,000 to 
$60,000 plus excellent benefits. For additional information contact: 
Community Physicians, Inc., 113 Landmark Square, Virginia 
Beach, Virginia 23452 (804) 486-0844. 

KIAWAH ISLAND: New, spacious home, three bedrooms, beautiful 
great room with lovely view overlooking lagoon: one block from 
oceanfront and golf course. $700/week. Telephone: (704) 542-2641 . 



August 1981. NCMJ 



613 



Index to 
Advertisers 



Air Force 591 

Boots Pharmaceuticals, Inc 563, 564, 565, 566 

Bristol-Myers Professional Products 527, 528. 

589, 590 

Burroughs Wellcome Company 521 

Charlotte Chest Laboratory 586 

Charlotte Treatment Center 614 

Children's Home Society of N.C 574 

Crumpton, J. L. & J. Slade, Inc 535 

Golden-Brabham Insurance Agency 612 

Graphic Cardiology 533 

Hedeco 540 

Lilly, Eli & Company 536 

Merrell Dow Pharmaceutical Inc. . . . 537. 538. 539. 

580, 581, 582 

Mandala Center 524 

Medical Mutual Insurance Company 522 



Mutual of Omaha 525 

National Medical Enterprises, Inc 592 

Ortega Pharmaceutical Company, Inc 584 

Plyler Financial Services 573 

Progressive Credit Corporation 579 

Provident Mutual Life Insurance Co 587 

Ramada Inn Downtown 526 

Roche Laboratories Cover 2, 519, 

Cover 3, Cover 4 

Sequoia Group, Inc 523 

Upjohn Company 571, 572 

Vyquest Development Corp 568 

Willingway. Inc 593 

Winchester Surgical Supply Company, 

Winchester-Ritch Surgical Company 520 

Wyeth Laboratories 531, 532, 576, 577 




FOR THE CHEMICALLY DEPENDENT 

At the Ctiarlotte Treatment Center we believe 
ttiat those who suffer from the treatable disease of 
alcoholism, and their families, are entitled to the same 
treatment and loving care as those suffering from 
any other disease. 



• Full time physician • Professional counseling staff 

• Psychiatric consultant • Family program 

• Registered nurses • After-care program 
AccredHed by Joint Commission on Accreditation of Hospitals (JCAH) 





ChailotteTreataMnt Center 

P O. Box 240197, 1715 Sharon Road West, Charlotle, N.C. 28224 For Information Call (704) 554-0285 

James F. Emmert, Executive Director 
Rex R. T«99art, M.D., Medical Director 



614 



Vol. 42. No. 8 



Bactrim 

(trimethoprim and sulfametlioxazole) ■ 

succeeds 



Expanding 



therapy 



Bactrim is useful for 
he following infec- 

?su£^bjf its usefulness in 

Saaantms antimicrobial 

see indications section 
T summary of product 
iformation): 




in recurrent 
UTI... 

a continuing record 
of high clinical 
effectiveness 
against common 
uropathogens 



in acute 
otitis media 
in children... 

effective against 
both major otic 
pathogens... with 
b.l.d. convenience 



in acute ex- 
acerbations 
of chronic 
bronchitis 
in adults... 

clears the sputum 
and lowers its 
volume... on b.i.d. 
dosage 



Before prescribing, please consult complete product information, a summary of 
wtiich follows: 

Indications and Usage: For ttie treatment of urinary tract infections due to 
susceptible strains of the fallowing organisms: Escherichia coll, Klebsiella-Entem- 
bacler, Proteus rtflrabllls, Proteus vulgaris, Proteus morganll. It Is recommended that 
Initial episodes of uncomplicated urinary tract infections be treated with a single 
effective antibacterial agent rather than the combination. Wo(e The increasing 
frequency of resistant organisms limits the usefulness of all antibaclenals, especially in 
these urinary tract infections 

For acute otitis media in children due to susceptible strains of Haemophilus 
Intluenzae or Streptococcus pneumoniae when in physician's judgment It offers an 
advantage over other antimicrobials. Limited clinical information presently 
available on effectiveness of treatment of otitis media with Bactrim when infection 
Is due to ampicillin-resistant Haemophilus Influenzae. To date, there are limited 
data on the safety of repeated use of Bactrim in children under two years of age. 
Bactrim is not Indicated for prophylactic or prolonged administration in otitis 
media at any age. 

For acute exacerbations of chronic bronchitis in adults due to susceptible strains 
of Haemophilus Intluenzae or Streptococcus pneumoniae when in physician's 
Judgment it offers an advantage over a single antimicrobial agent. 
For enteritis due to susceptible strains of Shigella tlexneri and Shigella sonnel 
when antibacterial therapy is indicated. 

Also for the treatment of documented Pneumocystis carlnii pneumonitis. To date, 
this drug has been tested only in patients 9 months to 16 years of age who were 
immunosuppressed by cancer therapy. 

Contraindications: Hypersensitivity to trimethoprim or sulfonamides; patients with 
documented megaloblastic anemia due to folate deficiency; pregnancy at term; 
nursing mothers because sulfonamides are excreted in human milk and may cause 
kernicterus, infants less than 2 months of age 

Warnings: BACTRIM SHOULD NOT BE USED TO TREAT STREPTOCOCCAL 
PHARYNGITIS. Clinical studies show that patients with group A ^-hemolytic 
streptococcal tonsillopharyngitis have higher incidence of bacteriologic failure when 
treated with Bactrim than do those treated with penicillin Deaths from hypersensitivity 
reactions, agranulocytosis, aplastic anemia and other blood dyscrasias have been 
associated with sulfonamides Experience with trimethoprim is much more limited but 
occasional interference with hematopoiesis has been reported as well as an increased 
incidence of thrombopenia with purpura in elderly patients on certain diuretics, 
primarily thiazides Sore throat, fever pallor, purpura or jaundice may be early signs of 
senous blood disorders Frequent CBC's are recommended; therapy should be 
discontinued if a siqnificantly reduced count of any formed blood element is noted. 
Precautions: General. Use cautiously in patients with 
impaired renal or hepatic function, possible folate 
deficiency, severe allergy or bronchial asthma. In 
patients with glucose-6-phosphate dehydrogenase 
deficiency, hemolysis, frequently dose-related, may 
occur During therapy maintain adequate fluid intake and 
perform frequent urinalyses, with careful microscopic 
examination, and renal function tests, particularly where 
there is impaired renal function Bactrim may prolong 
prothrombin time in those receiving warfarin; reassess 
coagulation time when administering Bactrim to these 
patients. 

Pregnancy: Teratogenic Effects; Pregnancy Category C. 
Because trimethoprim and sulfamethoxazole may inter- 
fere with folic acid metabolism, use during pregnancy 
only if potential benefits justify the potential risk to the 
fetus 

Adverse Reactions: All maior reactions to sulfonamides 
and trimethoprim are included, even if not reported with 
Bactrim. Blood dyscrasias- Agranulocytosis, aplastic 
anemia, megaloblastic anemia, thrombopenia, leuko- 
penia, hemolytic anemia, purpura, hypoprothrombinemia 
and methemoglobinemia Anergic reactions: Erythema 
multiforme, Stevens-Johnson syndrome, generalized skin eruptions, epidermal 
necrolysis, urticaria, serum sickness, pruritus, exfoliative dermatitis, anaphylactoid 
reactions, periorbital edema, conjunctival and scleral injection, photosensitization, 
arthralgia and allergic myocarditis Gastrointestinal reactions: Glossitis, stomatitis, 
nausea, emesis. abdominal pains, hepatitis, diarrhea and pancreatitis CNS reactions: 
Headache, peripheral neuritis, mental depression, convulsions, ataxia, hallucinations, 
tinnitus, vertigo, insomnia, apathy fatigue, muscle weakness and nervousness. 
Miscellaneous reactions: Drug lever, chills, toxic nephrosis with oliguria and anuria, 
penarteritis nodosa and L E phenomenon. Due to certain chemical similarities to some 
goitrogens, diuretics (acetazolamide, thiazides) and oral hypoglycemic agents, 
sulfonamides have caused rare instances of goiter production, diuresis and 
hypoglycemia in patients; cross-sensitivity with these agents may exist. In rats, long- 
term therapy with sulfonamides has produced thyroid malignancies. 
Dosage: Not recommended for infants less than two months of age. 
URINARY TRACT INFECTIONS AND SHIGELLOSIS IN ADULTS AND CHILDREN AND 
ACUTE OTITIS MEDIA IN CHILDREN: 

Adults Usual adult dosage for urinary tract infections— 1 DS tablet (double strength). 
2 tablets (single strength) or 4 teasp, (20 ml) b,i,d, for 10-14 days. Use identical daily 
dosage for 5 days for shigellosis. 

Children: Recommended dosage for children with urinary tract infections or acute otitis 
media— 8 mg/kg trimethoprim and 40 mg/kg sulfamethoxazole per 24 hours, in two 
divided doses lor 10 days. Use identical daily dosage for 5 days for shigellosis, 
for patients with renal impairment: Use recommended dosage regimen when creatinine 
clearance is above 30 ml/min. If creatinine clearance is between 15 and 30 ml/min, 
use one-hall the usual regimen, Bactrim is not recommended il creatinine clearance is 
below 15 ml/min 

ACUTE EXACERBATIONS OF CHRONIC BRONCHITIS IN ADULTS: 
Usual adult dosage: 1 DS tablet (double strength), 2 tablets (single strength) or 
4 teasp (20 ml) bid, for 14 days, 
PNEUMOCYSTIS CARINII PNEUMONITIS: 

Recommended dosage; 20 mg/kg trimethoprim and 100 mg/kg sulfamethoxazole per 
24 hours in equal doses every 6 hours (or 14 days. See complete product information 
for suggested children's dosage table. 

Supplied: Double Strength (DS) tablets, each containing 160 mg trimethoprim and 800 
mg sulfamethoxazole, bottles of 100; Tel-E-Dose» packages of 100; Prescription Paks 
of 20 and 28, Tablets, each containing 80 mg trimethoprim and 400 mg sulfamethox- 
azole— bottles of too and 500; Tel-E-Dose* packages of 100; Prescription Paks of 40. 
Pediatric Suspension, containing 40 mg trimethoprim and 200 mg sulfamethoxazole 
per teaspoonlul (5 ml); cherry-flavored— bottles ol 100 ml and 16 oz (1 pint). 
Suspension, containing 40 mg trimethoprim and 200 mg sulfamethoxazole per 
teaspoonful (5 ml); (ruit-iicorice flavored— bottles of 16 oz (1 pint). 



in shigellosis. 

faster relief of 
diarrhea than with 
ampicillin^ 



<Si 



■ rninur X "O^HE LABORATORIES 
HOCHc y Division of Hoffmann-La Roche Inc. 



Igi Nutley, New Jersey 07110 



in recurrent urinary tract infections 




from site to source Bactrim' DS 



160 mg trimethoprim and 800 mg sulfamethoxazole 
DOUBLE STRENGTH TABLETS 



Bactrim continues to demonstrate high clinical effec- 
tiveness in recurrent urinary tract infections. Bactrim 
reaches effective levels in urine, serum, and renal 
tissue' . . .the trimethoprim component diffuses into 
vaginal secretions in bactericidal concentrations'... 
and in the fecal flora, Bactrim effectively suppresses 
Enterobacteriaceae'^ with little resulting emergence 
of resistant organisms. 

1. Rubin RH, Swartz MN W Engl J Med 303 426-432, Aug 21 , 1980 2. Data on file. 
Medical Department. Hoffmann-La Rocfie Inc. 



maximizes results with B.I.D. convenience 



• due to susceptible strains of indicated organisms 



Please see previous page for summary of product information. 



North Carolina 

MEDICAL JOURNAL 



IThe Official Journal of the NORTH CAROLINA MEDICAL SOCIETY D D D September 1981, Vol. 42, No. 9 



Original Articles 

The Diminishing Mortality of Coro- 
nary Artery Bypass Grafting for 

Myocardial Ischemia 637 

Robert N. Jones, M.D.. Steven E. 
Curtis. Andrew S. Wechsler, 
M.D., W. Glenn Young. Jr., M.D., 
H. Newland Oldham, Jr., M.D., OCT 
Walter G. Wolfe, M.D., Robert 
Whalen, M.D., James J. Moig^^,Tij op 
M.D., Walter L. Floyd, M.D.. aM 
David C. Sabiston, Jr., M.D. 



Neonatal Cerebral Ultrasonography 642 

Ewell S. Roach, M.D., Richard L. 
Weaver, M.D., and William T. 
McLean. M.D. 

The Use of Psychotropics in the Prison 

Setting 645 

James H. Carter, M.D. 



Mini-Feature 

Toxic Encounters of the Dangerous 
Kind — Antihistamine Toxicity . 648 
Ronald B. Mack, M.D. 



Editorials 

Medicine and the Media 653 

Editorial Book Review 653 



North Carolina Division of 
Health Services 

Conjoint Report to North Carolina 

Medical Society 656 

Ron Levine, M.D., M.P.H. 



National Institutes of Health 

Consensus Development Confer- 
ence Statement. CEA (Carcino- 
embryonic Antigen): Its Role as a 
Marker in the Management of 
Cancer 660 

12 5981 

Correspondence 

lENC£SJ4§^^ophen Poisoning 665 

Shirley K. Osterhout, M.D., and 
Ronald B. Mack, M.D. 

Camphor Poisoning 666 

Shirley K. Osterhout, M.D. 

Bulletin Board 

New Members of the State Society 667 

What? When? Where? 667 

Auxiliary to the North CaroHna 

Medical Society 669 

News Notes from the University of 
North Carolina-Chapel Hill 
School of Medicine and North 
Carolina Memorial Hospital 673 

News Notes from the East Carolina 
University School of Medicine . . 680 

News Notes from the Bowman Gray 
School of Medicine of Wake 
Forest University 682 

Classified Ads 685 

Index to Advertisers 686 



1981 Committee Conclave: Sept. 23-27, 
Southern Pines 

1982 Conference for Medical Leadership: 

February 5-6, Winston-Salem 
1982 Annual Sessions: May 6-9, 
Pinehurst 



HESS AbVb31"l S2DNaijS Hi."ltfaH 

andwws 'O 'N =JD AiisoBAiNn 



1 



Feelii^^ vs 



Some people feel that I am misused and overused 
and that I'm prescribed too often and for too many kinds 
of problems. 

The FACT is that approximately eight million people, I 
or about 5 percent of the U.S. adult population, will use me ^ 
during the current year. By contrast, the national health 
examination survey (1971-1975) found that 25 percent of 
the U.S. adult population experiences moderate to severe 
psychological distress. Additionally, studies of patient atti- 
tudes revealed that most patients have realistic views regard- 
ing the limitations of tranquilizers and a strong conservatism , 
about their use, as evidenced by a general tendency to 'I 

^crease intake over time. Finally, a six-year, large-scale, 
carefully conducted national survey showed that the great 
majority of physicians appropriately prescribe tranquilizers. 

Some people feel that patients being treated with anxiolytic 
drugs are ''weak, " cant tolerate the anxieties ofnonnal daily 
living, and should be able to resolve their problems on their 
own without the help of medication. 

The FACT is that while most people can withstand 
normal, everyday anxieties, some people experience 
excessive and persistent levels of anxiety due to personal or 
clinical problems. An extensive national survey concluded 
that Americans who do use tranquilizers have substantial 



facts 



justification as evidenced by tiieir high levels of anxiety. It 
was further noted that antianxiety drugs are not usually 
prescribed for trivial, transient emotional problems. 

Some people feel afraid of me because of the stories 
they've heard about my being harmful and having the 
potential to produce physical dependence. 

The FACT is that there are thousands of references in 
the medical literature documenting my efficacy and safety. 
Extensive and painstakingly thorough studies of toxicological 
data conclude that I am one of the safest types of psycho- 
tropic drugs available. Moreover, I do not cause physical 
dependence if the recommended dosage and therapeutic 
regimen are followed under careful physician supervision. 
However, I can produce dependence if patients do not fol- 
low their physicians' directions and take me for prolonged 
periods, at dosages that exceed the therapeutic range. 
Patients for whom I have been prescribed should be cau- 
tious about their use of alcohol because an additive effect 
may result. 

Many of the most knowledgable people feel that I 
became the No. 1 prescribed medication in America because 
no other tranquilizer has been proven more effective. Or safer. 

The FACT is they are right. 



For a brief summary' of product information on Valium (diazepam/Roche) (w , please see the following 
page. Valium is available as 2-mg, 5-mg and 10-mg scored tablets. 



Valium® 

diazepam/Roche 



Before prescribing, please consult complete product 
information, a summary of which follows: 

Indications: Management o( anxiety disorders, or short- 
term relief of symptoms of anxiety Anxiety or tension 
associated with the stress of everyday life usually does 
not require treatment with an anxiolytic Symptomatic 
relief of acute agitation, tremor, delirium tremens and 
hallucinosis due to acute alcohol withdrawal, adjunctive- 
ly in skeletal muscle spasm due to reflex spasm lo local 
pathology, spasticity caused by upper motor neuron 
disorders; athetosis: stiff-man syndrome, convulsive 
disorders (not for sole therapy) 
The effectiveness of Valium (diazepam/Roche) in long- 
term use. that is, more than 4 months, has not been 
assessed by systematic clinical studies The physician 
should periodically reassess the usefulness of the drug 
for the individual patient 

Contraindicated: Known hypersensitivity to the drug. 
Children under 6 months of age Acute narrow angle 
glaucoma, may be used in patients with open angle 
glaucoma who are receiving appropriate therapy. 
Warnings: Nol of value in psychotic patients Caution 
against hazardous occupations requiring complete 
mental alertness When used ad|unctively in convulsive 
disorders, possibility of increase in frequency and/or 
severity of grand mal seizures may require increased 
dosage of standard anticonvulsant medication, abrupt 
withdrawal may be associated with temporary increase 
in frequency and/or severity of seizures Advise against 
simultaneous ingestion of alcohol and other CNS de- 
pressants Withdrawal symptoms similar to those with 
barbiturates and alcohol have been observed with 
abrupt discontinuation, usually limited to extended use 
and excessive doses Infrequently, milder withdrawal 
symptoms have been reported following abrupt discon- 
tinuation of benzodiazepines after continuous use, 
generally at higher therapeutic levels, for at least 
several months After extended therapy, gradually taper 
dosage Keep addiction-prone individuals under careful 
surveillance because of their predisposition to habitua- 
tion and dependence 

Usage in Pregnancy: Use of minor tranquil- 
izers during first trimester should almost 
always be avoided because of increased risk 
of congenital malformations as suggested in 
several studies. Consider possibility of preg- 
nancy when instituting therapy; advise 
patients to discuss therapy if they intend to 
or do become pregnant. 
Precautions: If combined with other psychotropics or 
anticonvulsants, consider carefully pharmacology of 
agents employed, drugs such as phenothiazines, nar- 
cotics, barbiturates. fvlAO inhibitors and other anti- 
depressants may potentiate its action Usual precautions 
indicated tn patients severely depressed, or with 
latent depression, or with suicidal tendencies Observe 
usual precautions m impaired renal or hepatic function 
Limit dosage to smallest effective amount in elderly and 
debilitated to preclude ataxia or oversedation 
The clearance of Valium and certain other benzodiaz- 
epines can be delayed in association with Tagamet 
(cimetidine) administration The clinical significance 
of this is unclear 

Side Effects: Drowsiness, confusion, diplopia, hypoten- 
sion, changes in libido, nausea, fatigue, depression, 
dysarthria, laundice, skin rash, ataxia, constipation, 
headache, incontinence, changes in salivation, slurred 
speech, tremor, vertigo, urinary retention, blurred vision. 
Paradoxical reactions such as acute hyperexcited 
states, anxiety, hallucinations, increased muscle spas- 
ticity, insomnia, rage, sleep disturbances, stimulation 
have been reported; should these occur, discontinue 
drug Isolated reports of neutropenia, laundice, periodic 
blood counts and liver function tests advisable during 
long-term therapy 

Dosage: Individualize for maximum beneficial effect 
Adults Anxiety disorders, symptoms of anxiety. 2 to 
10 mg b 1 d to q id,; alcoholism, 10 mg t i d or q i d 
in first 24 hours, then 5 mg t i d or q i d as needed, 
adjuncttvely in skeletal muscle spasm. 2 to 10 mg t i d 
or q i d . adjunctively in convulsive disorders, 2 to 10 mg 
bid toqid Geriatric or debililated patients 2 to 
2V2 mg, 1 or 2 times daily initially, increasing as needed 
and tolerated (See Precautions ) Children 1 to 2V2 mg 
t I d or q I d initially, increasing as needed and toler- 
ated (not for use under 6 months) 
Supplied: Valium" (diazepam/Roche) Tablets, 2 mg, 
5 mg and 10 mg— bottles of 100 and 500, Tel-E-Dose' 
packages of 100, available in trays of 4 reverse-num- 
bered boxes of 25, and in boxes containing 10 strips 
of 10; Prescription Paks of 50. available in trays of 10 



Roche Laboratories 

Division of Hoffmann-La Roche Inc. 

Nutley, New Jersey 07110 



NORTH CAROLINA 
MEDICAL SOCIETY 
MEETINGS 




Ul 
AHEi 



COMMIHEE CONCLAVE 
September 23-27, 1981 

Mid Pines Club 
Southern Pines, N.C. 



ANNUAL MEETING 

May 6-9, 1982 

Pinehurst Hotel 
Pinehurst, N.C. 



September 1981, Vol. 42, No. 9 



NORTH CAROLINA MEDICAL JOURNAL 

Published Monthly as the Official Organ o/The North Carolina Medical Society (lSSN-0029-2559) 



STAFF 

John H. Felts, M.D. 
Winston-Salem 

EOrTOR 

Mr. William N. Hilliard 
Raleigh 

BUSINESS MANAGER 



EDITORIAL BOARD 

Charles W. Styron, M.D. 
Raleigh 

CHAIRMAN 

George Johnson. Jr., M.D. 
Chapel Hill 

Edwin W. Monroe, M.D. 
Greenville 

Robert W. Prichard, M.D. 
Winston-Salem 

Rose Fully, M.D. 
Kinston 

Louis Shaffner, M.D. 
Winston-Salem 

Jay Arena. M.D. 
Durham 

Jack Hughes, M.D. 
Durham 



The appearance of an advertisement in this publication does not 
constitute any endorsement of the subject or claims of the 
advertisements. 

The Society is not to be considered as endorsing the views and 
opinions advanced by authors of papers delivered at the Annual 
Meeting or published in the official publication of the Society. 
— Constitution and Bylaws of the North Carolina Medical 
Society, Chapter IV, Section 4, page 4. 

NORTH CAROLINA MEDICAL JOURNAL, 300 S. Haw- 
thorne Rd.. Winston-Salem. N.C. 27103, is owned and pub- 
lished by The North Carolina Medical Society under the direc- 
tion of its Editorial Board. Copyright® The North Carolina 
Medical Society 1981. Address manuscripts and communica- 
tions regarding editorial matter to this Winston-Salem address. 
Questions relating to subscription rates, advertising, etc.. 
should be addressed to the Business Manager, Box 27167, 
Raleigh, N.C. 27611. All advertisements are accepted subject 
to the approval of a screening committee of the State Medical 
Journal Advertising Bureau, 711 South Blvd., Oak Park, 
Illinois 60302 and/or by a Committee of the Editorial Board of 
the North Carolina Medical Journal in respect to strictly local 
advertising. Instructions to authors appear in the January and 
July issues. Annual Subscription, $12.00. Single copies, $2.00. 
Publication office: Edwards & Broughton Co. , P.O. Box 27286, 
Raleigh, N.C. 27611. Second-class postage paid at Raleigh. 
North Carolina 2761 1. 





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200 South Torrence St. Charlotte, N.C. 28204 

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MEDICAL SUPPLY DIVISION FOR YOUR PATIENTS AT HOME 

1500 E. THIRD STREET Phone No. 704/332-1217 

Winchester-Ritch Surgical Company 

421 West Smith St. Greensboro, N.C. 27401 
Phone No. 919-273-5581 

Serving the MEDICAL PROFESSION of NORTH CAROUNA 
and SOUTH CAROUNA aince 1919. 

We equip many new Doctors beginning practice each year, and invite your inquiries. 

Our stdesmen are located in idl parts of North Carolina 

We have DISPLAYED at every N.C. State Medical Society Meeting since 1921, and advertised 
CONTINUOUSLY in the N.C. Journal since January 1940 issue. 



NORTH CAROLINA MEDICAL SOCIETY 
APPROVED INSURANCE PROGRAMS 

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$25,000 maximum benefit: choice of deductibles from $100 to $1,000: benefits 
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Excess Major Medical Insurance 

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Term Life Insurance 

Coverage from $10,000: dependents and employees eligible 

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GETA BIGGER SUCE 
OF LIFE. 



You can expect to 
add an actual 11 
extra years 
to your life, if 
uou follow 
these7rules. 




1 Start each day with breakfast. 
Your body needs refueling in 
the AM. Try a sandwich or spaghetti 
if your taste isn't for cereal, bacon 
or eggs. 

2 Eat three meals a day. 
Skipping meals could shorten 
your life, so eat regularly and wise|>^ 
—three square meals a 
day to stay healthy 

3 Limit 
alcoholic 
beverages. 
If you drink, do 
it in moderation 
Try to avoid drink 
served on the rocks 
straight up. Have some food 
in your stomach. And sip, don't gulp 

4 Limit your smoking . 
If you smoke, use moderation. 
Don't smoke your cigarette all the 
way down. Limit the number of cig- 
arettes you smoke. Don't smoke 
till noon. You'll breathe a lot easier 
if you cut down a little or even stop. 

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Each extra pound you put on 
brings you closer to diseases of 
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Eollow your doctor's advice. 



©1979 Blue Cross and Blue Shield of North Carolina, Durham. Norlh Carolina 



6 Schedule enough sleep 
Your body needs enough time 
to rest. Get 7-8 hours sleep if you're 
between 20 and 55. If you're over 
55, you could get by on slightly less. 

7 Get plenty of exercise . 
Long walks count as exercise. 
So does dancing, gardening, climb- 
ing stairs. Plan to get moderate 



exert i^e ot some sort two or three 
times a week. 

For a free brochure on how to get 
all the life that's coming to you, 
write to: Public Relations, Blue 
Cross and Blue Shield of North 
Carolina, PO. Box 2291 , Durham, 
North Carolina 27702. 




Blue Cross 
Blue Shield 



®- of Nortti Carolina 



Officers 
1981-1982 

NORTH CAROLINA MEDICAL 
SOCIETY 



President Josephine E. Newell, M.D. 

Raleigh Townes. Apt. 47. 52.'i Wade Ave., Raleigh 27605 

Presidenl-EU'ct Marshall S. Redding, M.D. 

1142 N. Road St., Elizabeth City 27909 

First Vice-President John W. Foust, M.D, 

3535 Randolph Rd., Charlotte 28222 

Second Vice-President Emery C. Miller, Jr., M.D. 

Bowman Gray, Winston-Salem 27103 

Secretary' Jack Hughes, M,D. 

923 Broad St.. Durham 27705 (1982) 

Speaker Henry J. Carr, Jr,. M.D, 

603 Beaman St,, Clinton 28328 

Vice-Speiil<er T. Reginald Harris, M.D. 

808 Schenck St., Shelby 28150 

Past-President Frank Sohmer, M.D. 

2240 Cloverdale Ave.. Ste. 88, Winston-Salem 27103 

Executive Director William N, Hilliard 

222 N, Person St,, Raleigh 2761 1 

Councilors and Vice-Councilors — 1981-1982 

First District Robert E. Lane, M,D. 

Chowan Med. Ctr.. Edenton 27932 (1983) 

Vice-Councilor James M. Watson, M,D, 

1134 N, Road St., Elizabeth City 27909 (1983) 

Second District Charles P. Nicholson, Jr,, M,D. 

3108 Arendell St., Morehead City 28557 (1982) 

Vice-Councilor Alfred L. Ferguson, M.D. 

6 Doctors Park, Stantonsbiirg Rd,, Greenville 27834 (1982) 

Tliird District R. Bertram Williams, Jr.. M.D. 

1414 Medical Center Dr., Wilmington 28401 (1982) 

Vice-Councilor Charles L, Garrett, Jr,, M,D, 

P.O. Box 1358, Jack.sonville 28540 (1982) 

Fourth District Robert H. Shackelford. M.D. 

238 Smith Chapel Rd.. Ml. Olive 28365 (1983) 

Vice-Councilor Lawrence M. Cutchin, Jr,, M,D, 

P.O. Box 40, Tarboro 27886 (1983) 

Fifth District Bruce B, Blackmon, M,D, 

P.O, Box 8, Buies Creek 27506 (1984) 

Vice-Councilor Giles L. Cloninger, Jr., M,D, 

115 Main St., Hamlet 28345 (1984) 

Sixth District W. Beverly Tucker, M,D, 

Ruin Creek Rd., Henderson 27536(1983) 

Vice-Councilor C. Glenn Pickard, Jr.. M.D. 

N.C. Memorial Hospital, Chapel Hill 27514 (1983) 

Seventh District James B, Greenwood, Jr.. M.D. 

4101 Central Avenue. Charlotte 28205 (1984) 

Vice-Councilor Thomas L. Dulin, M.D. 

P.O. Box 220892. Charlotte 28222 (1984) 

Eighth District , . Shahane R. Taylor. Jr., M.D. 

348 N. Elm St., Greensboro 27401 (1982) 

Vice-Councilor L Gordon Early, M,D. 

2240 Cloverdale Ave., Ste, 192, Winston-Salem 27103 (1982) 

Ninth District Jack C. Evans, M.D. 

244 Fairview Dr., Lexington 27292 (1982) 

Vice-Councilor Benjamin W. Goodman, M.D. 

24 Second Ave., N.E., Hickory 28601 (1982) 

Tenth District Charles T. McCullough. Jr., M.D. 

Bone & Joint Clinic, Doctors Dr., Asheville 28801 (1984) 

Vice-Councilor George W. Brown, M.D. 

102 Brown Ave.. Hazelwood 28738 (1984) 



Section Chairmen 

Allergy & Clinical Imnuinology . . . 



1981-1982 



Anesthesiology J. LeRoy King, M.D. 

3600 New Bern Ave.. Raleigh 27610 

Dernuitologv Charles E. Cummings, M.D, 

281 McDowell Street. Asheville 28803 

Emergency Medicine 

Fumih Practice Hal M. Stuart, M,D, 

180-C Parkwood Dr,, Elkin 28621 

Internal Medicine William R. Bullock, M.D. 

217 Travis Avenue. Charlotte 28204 

Neurological Surgery Robert E, Price, Jr,. M,D. 

1830 Hillandale Rd., Durham 27705 

Neurology & Psychiatry Assad Meymandi. M.D. 

1212 Walter' Reed Road, Fayetteville 28304 

Nuclear Medicine William McCartney, M.D. 

N.C. Memorial Hosp., Dept. of Nuclear Medicine, 
Chapel Hill 27514 

Obstetrics & Gynecology Talbot E, Parker, Jr,, M,D. 

2400 Wayne Memorial Drive, Ste. K. Goldsboro 27530 

Ophthalmology J. Lawrence Sippe, M,D, 

1350 S. Kings Drive, Chariotte 28207 

Orthopaedics Richard N, Wrenn, M,D, 

1822 Brunswick Avenue, Chariotte 28207 
Otolaryngology & Maxillofacial 

Surt>ery Walter R. Sabiston, M.D. 

400 Glenwood Ave., Kinston 28501 

Patholo(>y Ron Edwards. M.D. 

3000 New Bern Ave., Raleigh 27610 

Pediatrics DavidT. Tayloe, M.D. 

608 E. 12th St.. Washington 27889 
Plastic & Reconstructive 

Surgery Andrew W. Walker, M.D. 

2215 Randolph Rd.. Charlotte 28207 

Public Health & Education Verna Y. Barefoot, M,D. 

2504 Old Cherry Point Rd., New Bern 28560 

Radiology Luther E. Earnhardt. Jr., M.D. 

Executive Park, Ste, 203, Asheville 28801 

Surgery Carl A. Sardi, M.D, 

Climax 27233 

Urology Donald T, Lucey, M.D. 

P.O. Box 17908, Raleigh 27619 

Delegates to the American Medical Association 

James E. Davis, M,D,, 2609 N. Duke St., Ste, 402, Durham 27704 

— 2-year term (January 1, l98l-December 31 , 1982) 
John Glasson,M.D.. 2609 N. Duke St.. Ste. 301. Durham 27704 — 

2-year term (January 1, 1981-December 31 , 1982) 
David G. Welton. M.D.. 3535 Randolph Rd.. lOI-W. Charlotte 

28211 — 2-year term (January 1. 1980-December 31 . 1981) 
Frank R. Reynolds, M,D,. 1613 Dock St.. Wilmington 28401 — 

2-year term (January 1. 1981-December 31 , 1982) 
Louis deS, Shaffner. M.D., Bowman Gray, Winston-Salem 

27103 — 2-year term (January 1. 1980-December 31, 1981) 

Alternates to the American Medical Association 

E, Harvey Estes, Jr,, M.D.. Duke Med. Ctr., Box 2914, Durham 
27710 — 2-year term (January 1, 1981-December 31 , 1982) 

Charles W. Styron. M.D.. 615 St. Mary's St., Raleigh 27605 — 
2-year term (January 1. 1980-December 31 , 1981) 

D, E. Ward. Jr.. M.D., 2604 N, Elm St.. Lumberton 28358 — 
2-year term (January 1. 1980-December 31 . 1981) 

Jesse Caldwell, Jr., M.D., 1307 Park Lane, Gastonia 28052 — 
2-year term (January 1, 1981-December 31 , 1982) 

Frank Sohmer, M.D., 2240 Cloverdale Ave,, Ste. 88, Winston- 
Salem 27103 — 2-year term (January 1, 1981-December31, 1982) 



620 



Vol, 42. No. 9 






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\CE THE ACHE 

vith 



Equagesic® 

meprobamate and ethoheptazine citrate with aspirin) Wyeth 

fwofold analgesic action teamed with time-proven efficacy against 
concurrent anxiety and tension in patients with musculoskeletal disease* 



3UAGESIC— Abtjfevialed Summary 



•rNDlCATIONS: Based on a reuiew of Ihis flrug bv the 
Nalionai Academy o' Sciences— National Research 
Counci: and or other mlormalton FDA has Classified 

I the mdications as follows 

, 'PossiOly" eMectrve 'or the treatmenl of pain accom- 

. oaried by tension and or anxiety in patients with mus- 
culoskeletal disease or tension headache 
Final classidcaton of the less -than -effective indications 
requires luriher investigation 

The effectiveness of Equagesic in long-term use. i e 
more than lour months, has not been assessed by sys- 
tematic clinical studies The physician should periodi- 
cally reassess usefulness of the drijg for the individual 
patient 



JNTRAINDICATIONS: Equagesic should not be given to 
lividuals wTih a hisiorv ol sensrtivrty or severe intolerance 
aspmn, meprobamate or ethofieplazme citrate 
ARNINGS; Careful supervision of dose and amounts pre- 
■ibed for patients is advised, esDeciaUy with idose patients 
fi known propensity lor taking excessive quantrties Of drugs 
cessive and prolonged use in susceptible perspns e g 
jOholtcs. former addicts and other severe psychoneuroi- 
;. has been reported to result m dependence en or habii- 
,fion lo the drug Where excessive dosage has continued 
(weeks or months, dosage should be reduced gradually 
ner than aoruptly stopped, since withdrawal ot a "crutch 
|y precipitate withdrawal reaction ol greater proportions 
in that lor which the drug was originally prescnbed Abrupt 
,»ntimjance of doses in excess of the recommended dose 
|5 resulted in some cases in the occurrence ot epileplilorm 
Jzufes 

[Ma] care should be taken lo warn palienis taking mepro- 
nale that tolerance to alcohol may be lowered wilh result- 
slowing of reaction lime and impatrmeni pt judgment and 
'rdination 

AGE IN PREGNANCY AND LACTATION: An increased 
( ol congenital mallormalions associated wilh the use 



ol minor tranquilizers tmeprobamate. chlordiazepoxide. 
and diazepam) during the first trimester at pregnancy 
has been suggested m several studies Because use of 
these drugs is rarely a matter ol urgency, their use dur- 
ing this period should almost always be avoided The 
possibility that a woman of child-beanng potential may 
be pregnant at the time ol institution ol therapy should 
be considered. Patients should be advised that if they 
t>ecome pregnant during therapy or intend to become 
pregnant they should communicate wilh their physi- 
cians aboul the desirability ol discontinuing the drug. 
Meprobamate passes the placental barrier It is preseni 
both in umbilical-cord blood at or near maternal plasma 
levels and in breast milk ol lactatmg mothers at concen- 
trations two to lour limes that ot maternal plasma. When 
use ol meprobamate is contemplated m breasl-leeding 
patients, the drug's higher concentration in breast milk 
as compared to maternal plasma levels should be 
considered. 

Preparations containing aspinn should be kepi out of the 
reach of children Eguagesic is not recommended for pa- 
Henls 12 years ot age and under 

PRECAUTIONS: Should drowsiness, ataxia, or visual distur- 
bance occur, the dose should be reduced If symptoms con- 
tinue, patients should not operate a motor vehicle or any 
dangerous machinery 

Suicidal attempts with meprobamate have resulted m coma 
shock vasomotor and respiratory collapse, and anuna Very 
few suicidal attempts were fatal, although some patients in- 
gested very large amounts of the drug (20 to 40 gm) These 
doses are much greater than recommended The drug should 
be given cautiously, and in small amounts lo patients who 
have suicidal tendencies m cases where excessive doses 
have been taken sleep ensues rapidly and blood pressure 
pulse and respiratory rates are reduced to basal levels Hy- 
pe rven illation has been reported occasionally. Any drug re- 
maining in the stomach should be removed and symptomatic 
treatment given Should respiration become very shallow and 
slow CNS stimulants, e g caffeine Melrazol or ampheta- 



mine, may be cautiously administered il severe hypotension 
develops, pressor amines should be used parenlerally to re- 
store blood pressure to normal levels 

ADVERSE REACTIONS: A small percentage ol patients 
mav expenence nausea with or without vomiting and epigas- 
tric distress Dizziness occurs rarely when meprobamate and 
ethoheptazine citrate wilh aspinn is administered in recom- 
mended dosage The meprobamate may cause drowsiness 
tjul, as a mie, this disappears as therapy is continued Should 
drowsiness persist and be associated with ataxia this symp- 
tom can usually be controlled by decreasing ihe dose, but 
occasionally it may be desirable to administer central stimu- 
lants such as amphetamine or mephentermme sulfate con- 
comitantly to control drowsiness 

A clearly related side effect to Ihe administration of mepro- 
bamate IS the rare occurrence of allergic or idiosyncratic re- 
actions This response develops, as a rule m patients who 
have had only 1-4 doses of meprobamate and have not had 
a previous contact with the drug Previous history ot allergy 
may or may not be related to the incidence ol reactions 
Mikl reactions are characlenzed by an itchy urncanal or ery- 
thematous, maculopapuiar rash which may be generalized 
or conlined to the groin Acute nonlhrombocyiopenic purpura 
with cutaneous peiechiae ecchymoses peripheral edema, 
and fever have also been reporied 

More severe cases observed only very rarely, may also have 
Other allergic responses, including fever fainting spells, an- 
gioneurotic edema, bronchial spasms, hypotensive cnses (1 
fatal case), anaphylaxis, stomatitis and proctitis (1 case) and 
hyperthermia Trealmeni should be symptomatic such as 
administration ol epinephrine, antihistamine, and possibly 
hydrocortisone Meprobamate should be stopped, and rein- 
stitulion of therapy should not be attempted 
Rare cases have been reported where patients receiving me- 
probamate suffered from aplastic anemia (1 fatal easel 
thrombocytopenic purpura agranulocytosis and hemolytic 
anemia In nearly every instance reported, other toxic agents 
known lo have caused these conditions have been associ- 
ated with meprobamate A few cases of leukopenia during 



continyous admirislralion ol meprobamate are reported most 
of these returned lo normal withoul discontinuation of the 
drug 

Impairment of accommodation and visual acuity has been 
reported rarely 

OVERDOSE: Two instances of acodenlal or intentional sig- 
nificant overdosage with ethoheptazine curate combined with 
aspirin have been reported These were accompanied by 
symptoms ol CNS depression, including drowsiness and light- 
headedness with uneventful recovery However, on the basis 
of pharmacological data it may be anticipated that CNS stim- 
ulation could occur Other anticipated symptoms would in- 
clude nausea and vomilmg Appropnaie therapy ol signs and 
symptoms as they appear ts the only recommendation pos- 
sible at this lime Overdosage with eihohepiazme comliined 
wilh aspirin would probably produce Ihe usual symptoms and 
signs ol salicylate intoxication Observalion and treatment 
Should include induced vomiting or gastric lavage specific 
parenteral electrolyte therapy (or ketoacidosis and dehydra- 
tion watching lor evidence of hemorrhagic manifestations 
due lo hypoprothrombinemia which il it occurs usually re- 
Quites whole-blood transfusions. 

DESCRIPTION: Each Equagesic tablet contains 150 mg me- 
probamate. 75 mg ethpheplazine dtraie and 250 mg aspinn 

Copyright = 1961. Wyelh Laboralones 
All rights reserved 

"This drug has been evaluated as possibly 
effective lor this mdicalion 

Wyeth Laboratories 

' • Philadelphia. PA 19101 



\AJ 



r/'^ 



Dow 



Step 




for mild to moderate pain 

Wygesic® 

(65 mg propoxyphene HCI and 650 mg acetaminophen) Wyeth 



More than twice as much acetaminophen as the leading combination plus a full 
therapeutic dose of propoxyphene... all in a convenient, economical single tablet. 



WYGESIC— Abbreviated Summary 
INDICATION f : f trie reliel ot mild-1o-moderale pain 
CONTRAINDICATION: Hypersensttivily lo propox- 
vL''''"''- ■-■■ ''■ ■!■ I'Uiininophen 

WARNINGS "'IS ADDITIVE EFFECTS AND OVER- 
DOSAGE Propoxyphene in compinahon wilh alcohol, 
tranquilizers, sedalive-hypnolics or olher CNS de- 
pressants has an additive depressant eMecl Pa- 
tients taking this drug should be advised of the additive 
ellect and warned not lo exceed the dosage recom- 
mended Toxic effects and fatalities have occurred 
lollowmg overdoses of propoxyphene alone or in 
combination with other CMS depressants Most of 
these patients had histories of emotional disturb- 
ances or suicidal ideation or attempts, as well as 
misuse of tranquilizers alcohol or olher CNS-active 
drugs Caulion should be exercised m prescribing 
large amounts o( propoxyphene lor such patients 
(see Management of Overdosage) 
DRUG DEPENDENCE; Propoxyphene can produce 
drug dependence characterized by psychic depend- 
ence and less frequently physical dependence and 
loierance It wili only partially suppress the with- 
drawal syndrome m individuals physically dependent 
on morphine or other narcotics The abuse liability ot 
propoxyphene ts qualitatively similar to codeme s al- 
though Quantitatively less and propoxyphene should 
be prescribed with the same degree ot caution ap- 
propriate to the use of codeine 

USAGE IN AMBULATORY PATIENTS; Propoxy- 
phene may impair the mental and/or physical abilities 
required for potentially hazardous tasKs, e g driving 
a car or operating machinery Patients siiould be 
cautioned accordingly 

USAGE IN PREGNANCY; Sale use m pregnancy 
has not ^i^^vK established relative lo possible ad- 
verse elfecis on fetal development INSTANCES OF 
WITHDRAWAL. SYMPTOMS IN THE NEONATE 
HAVE BEEN REPORTED FOLLOWING USAGE 
DURING PREGNANCY Therefore propoxyphene 
should not be used m pregnant women unless, in the 



ludgemenl ol the physician, the potential benedts 
oulweigh ihe possible hazards 

USAGE IN CHILDREN; Propoxyphene is not rec- 
ommended lor cfiildren because documented clinical 
experience has been insufficient to establish salety 
and a Suitable dosage regimen m the pediatric group 
PRECAUTIONS: Confusion anxiety, and tremors 
have been reported m a lew patients receiving pro- 
poxyphene concomilantly with orphenadnne The CNS 
depressant eiieci ot propoxyphene may be additive 
with other CNS depressants, including alcohol 
ADVERSE REACTIONS: The mosl frequent ad- 
verse reactions are dizziness sedation nausea and 
vomiting These seem more prominent in ambulatory 
than in nonambulatory patients some ol Ihese re- 
actions may be alleviated i( the patient hes down 
Olher adverse reactions include constipation, ab- 
dominal pain, skin rashes, iight-headedness. head- 
ache, weakness, euphoria, dysphoria, and minor 
visual disturbances The chrome ingestion of propox- 
yphene in doses over 800 mg per day has caused 
toxic psychoses and convulsions Cases of liver dys- 
function have been reported 

DRUG INTERACTIONS: Propoxyphene in combi- 
nation with alcohol, tranquilizers, sedative-hypnot- 
ics and other CisiS depressants has an additive 
depressant etiect Patients lading this drug should 
be advised oi the additive ellect and warned not to 
exceed ihe dosage recommended (see Warnings) 
Contusion anxiety and tremors have been reported 
m a few patients receiving propoxyphene concomi- 
tantly with orphenadnne 

MANAGEMENT OF OVERDOSAGE: SYMPTOMS 
The manitestalions of serious overdosage with pro- 
poxyphene are similar lo those of narcotic overdos- 
age and include respiratory depression (a decrease 
m respiratory rale and or lidal volume, Cheyne- 
Stokes resp;ration, cyanosis), exlreme somnolence 
progressing to stupor or coma, pupillary constriction 
and Circulatory collapse In addiiion to these char- 
acteristics, which are reversed by nafcotic antago- 



nists such as naloxone, there may be other effects 
Overdoses of propoxyphene can cause delay of car- 
diac conduction as well as local or generalized con- 
vulsions, a prominent feature in most cases ol severe 
poisoning Cardiac arrhythmias and pulmonary edema 
have occasionally been reported, and apnea, car- 
diac arrest, and death have occurred 
Symptoms of massive overdosage with acetamino- 
phen may include nausea, vomilmg anorexia, and 
abdominal pam, beginning shortly after ingestion and 
lasting for 12 to 24 hours However, early recognition 
may be difficult since eany symptoms may be mild 
and nonspecific Evidence of liver damage is usually 
delayed After the initial symptoms, the patient may 
feel less 111. however laboratory determinations are 
lively to show a rapid rise m liver enzymes and bili- 
rubin In case of serious hepatotoxtcity. laundice, co- 
agulation defects, hypoglycemia, encephalopathy, 
coma and death may follow Renal failure due to 
tubular necrosis, and myocardiopathy. have also been 
reported 

Ingestion of 10 grams or more ol acefaminoDhen 
may produce hepatoloxicily. A 13-gram dose has re- 
portedly been fatal 

TREATMENT: Primary altenlion should be given lo 
the reeslablishmenl ol adequate respiratory ex- 
change through provision of a patent airway and in- 
stitution of assisted or controlled ventilation The 
narcotic antagonists, naloxone nalorphine and lev- 
aiiorphan. are specific antidotes against the respira- 
tory depression produced by propoxyphene An 
appropriate dose of one ol these antagonists should 
be administered preferably I V .simultaneously withef- 
lorts at respiratory resuscilaiion and the antagonist 
should be repeated as necessary until the patients 
condition remains satisfaciory In addition to a nar- 
cotic antagonist, the patient may require careful liira- 
lion with an anticonvulsant to control seizures 
Analeptic drugs {e g caffeine or amphetamine) should 
not be used because of their tendency lo precipitate 
convulsions 



Oxygen IV fluids vasopressors and Olher suppoi 
live measures should be used as indicated Gasln 
lavage may be helpiui Activated charcoal can at 
sorb a signilicant amount of ingested propoxypheni 
Dialysis is of little value m poisoning by propoX) 
phene alone Acetaminophen is rapidly absorbet 
and efforts to remove the drug from the body sfioul 
not be delayed Copious gastnc lavage and or indu( 
lion of emesis may be indicated Activated charco; 
IS probably ineffective unless administered almo! 
immediately after acetaminophen ingestion Neithf 
forced diuresis nor hemodialysis appears to be e 
feclive m removing acetaminophen Smce acelam 
nophen m overdose may have an antidiuretic eflet 
and may produce renal damage administration 
fluids should be carefully monitored to avoid ove 
load It has been reported that mercaptamme (cy; 
teamme) or other thiol compounds may protect again 
liver damage if given soon after overdosage (8-1 
hours) N-acetylcysteine is under investigation as 
less toxic alternative to mercaptamme, which m; 
cause anorexia, nausea, vomiting, and drowsiness 
Appropriate literature should be consulted for furlhi 
information (JAMA 237 2406-2407, 1977) 
Clinical and laboratory evidence ol hepalotoxicily 
be delayed up to one week Acetaminophen plasrr 
levels and half-life may be useful m assessing If" 
likelihood of hepatotoxicity Serial hepatic enzyrr 
determinations are also recommended 

Copyright 'C 1981, Wyeth Laboratories. 
All rights reserved 

Wyeth Laboratories 

■■ ■ Philadelphia, PA 19101 



\AA 




PRESIDENT'S NEWSLETTER 

NORTH CAROLINA MEDICAL SOCIETY 



■40. 4 



SEPTEMBER 1981 



Dear Colleagues: 

Finally on July 29, 1981, Senate and House Conferees reached an agreement on the 
health provisions of the Reconciliation Bill. At last, the states know what federal 
funds can be expected for each Medicaid Program and the major regulatory changes 
in both the Medicaid and Medicare Programs. 

MEDICARE PART B 

■1. DROPPED was a provision mandating the calculation of statewide median charges 
for physician services. This figure was to be used to limit increases in phy- 
sician reimbursement. 



No part of beneficiaries' expenses can be "carry over" expenses from one year 
to meet the deductible the next year. 

Medicare Part B deductible will be increased from $60 to $75. 

Separate prospective uniform reimbursement rates for renal dialysis services 
will be established for free-standing facilities and hospitals. 

A civil monetary penalty of $2,000 can be imposed for fraudulent claims under 
Medicare or Medicaid. 

Occupational therapy will not be recognized as a sole criteria for qualifying 
for home health services. 



Medicare will pay for pneumococcal vaccine. 

"In establishing reasonable charge limitations for hospital outpatient services, 
the limits must be reasonably related to the reasonable charges for similar 
services provided in a physician's office." 

MEDICAID 

A target rate of expenditures will be set for FY82 at 109% of FY81 expenditures, 
indexed in the following two years to the medical component of the CPI. Federal 
reimbursement to Medicaid Programs will be reduced by 3% in FY82, 4% in FY83 and 
4.57o in FY84. States will receive federal dollars of at least the target rate. 

1. Freedom of choice was NOT eliminated. 

2. States MAY reimburse hospitals at less than the Medicare rate. 

3. The EPSDT penalty was eliminated. 






i 



4. States will NOT be required to provide Medicaid coverage to persons over 21 
who would be eligible for AFDC if they were in school. 

5. Payment will be made for non-medical services (except for room and board) if 
such services would avoid placement of a recipient in a facility and does not 
increase total long-term care costs. 

6. Federal dollars will NOT pay for the costs of tests in hospitals unless they 
are SPECIFICALLY ORDERED by the attending physicians or other responsible 
practitioner . 

7. States will NOT be required to provide services to all groups of Medically 
Needy. A state may offer whatever mix of services it determines is appropriate 
for each group of needy. 

In the meantime, uncontrollable Medicaid costs increased from $16.48 billion to 
$17.1 billion in FY1981. Conservative estimates for FY1982 are $18.74 billion. 
Those of us, who are older, remember that organized medicine repeatedly warned the 
Feds of this probability as early as the late 1940's. Nobody listened! Z 

The General Accounting Office (GAO) is highly critical of the Health Planning 
Program. GAO reported that "despite major commitments of money ($750 million) and 
community effort, health systems plans (HSP) were inadequately developed and did 
not represent a good framework for making needed changes in the health care system". 
They further stated that the HSP ' s were generally "totally unusable," a waste of 
tremendous amounts of money; and, if done at all, should be done at the state level 

In the July 1981 MEDICAID BULLETIN, we were notified that: ' ; 

"Medicaid payments made to practitioners on or after August 1, 1981, will 
be at 5070 of the co-insurance amount and 90% of the deductible amount for 
Medicare crossover claims ." 

This action will considerably reduce Medicaid payments to physicians who care for 
Medicare/Medicaid "crossover" patients. Consequently, I asked Sarah T. Morrow, M.D., 
to assist us by obtaining an explanation for this action in the General Assembly. 
At Dr. Morrow's request, Mr. John A. Williams, Jr., State Budget Officer, responded 
that the General Assembly had taken this action "to make all Medicaid reimbursement 
procedures consistent by mandating that Medicare 'crossover' claims be paid at 
Medicaid rates. Unfortunately, this had the effect of further reducing payments 
made to physicians." Mr. Williams further stated; "We regret that this has occurred^} 
and we want to assure you that we will continue working to address your concerns." i. 
Well, we ARE concerned! p 

After consultation with President-Elect Marshall S. Redding and the Chairman of 
the Committee on Social Services, Joseph D. Russell, M.D., I responded to Mr. 
Williams' letter (see on page 4) in an effort to actively request the support of 
the Administration in seeking relief from the implementation of this most recent 
reduction in reimbursement for physician services in the North Carolina Medicaid 
Program. Joe Russell and I plan to visit with Dr. Morrow and Barbara D. Matula, 
Director of the North Carolina Division of Medical Assistance, to further voice 
the concern of the North Carolina Medical Society in regard to this abrupt ruling 
which will further penalize physicians who are providing medical care for elderly 
Medicaid patients. You ma>' be sure that this matter will be a major topic of dis- 
cussion for the Committee on Social Services Programs at its meeting on Thursday, 
September 24, 2:00-5:00 p.m. at the Mid Pines Club. PLEASE plan to be at the 



-3- 



Committee Conclave in Southern Pines, September 23-26, 1981 whether or not you 

serve on a committee! Remember you are the North Carolina Medical Society! Try 

to be present and to be heard on all these grave matters which so greatly affect 
the practice of medicine and the health care of all North Carolinians. 

To my great surprise, I learned that the PRESIDENT'S NEWSLETTER is circulated to 
other state societies. Robert W. Clark, M.D., President of the Nevada State Medical 
Association not only read the last issue but was good enough to write me a letter 
of condolence. Dr. Clark wrote: 

"I appreciated receiving a copy, although it was very depressing, for 
all of the problems stated in your newsletter that you are having are 
virtually identical to my newsletter, dated two months earlier, except 
for the name of the state. I wish I could offer encouragement, and I 
hope that somebody has a victory someplace, at least on one of these 
issues . " 

Thank you. Dr. Clark. As the "ol' feller" said "misery loves company". 

I hope to see you all in Southern Pines where we shall re-group, fling out the 
banner, and march forward, together ! There is NO retreat from the problems which 
face medicine! 



My best to you and your family, 




Josephime E. Newell, M.D. 
Presiaent 






fI 



COPY 



COPY 



COPY 



COPY 



COPY COPY 



August 24, 1981 

John A. Williams, Jr., State Budget Officer 

Office of State Budget and Management 

116 W. Jones Street 

Raleigh, North Carolina 27611 

Dear Mr. Williams: 

Thank you for your letter of August 21, 1981, in response to my request for 
an explanation of recent further reduction in reimbursement for physician services 
in the North Carolina Medicaid Program. Although I understand that this unfortuna^ 
decision was made in the General Assembly. I must ask your assistance in seeking 
relief from this most recent action which will surely discourage practicing physi- 
cians from participation in the Medicaid Program. 

As the Division of Medical Assistance must be well aware, physician reimburse- 
ment for Medicaid services barely covers office overhead costs and, often, is less., 
than office overhead to the physician. For the past two years, I have worked close! 
in the Medicaid Program and have seen many of the inequities in reimbursement. 
We, the physicians of North Carolina, do understand the tremendous responsibility 
of administration which Medicaid imposes, as well as the gigantic tax burden it 
has become for all taxpayers. Every member of the North Carolina Medical Society 
is, also, a taxpaying North Carolina citizen. 

Because of the burden of overwhelming paperwork and regulations, as well as 
financial loss for services rendered, it has been difficult to enroll physicians 
in the Medicaid Program. Since this most recent reduction will affect only 
Medi care /Medi caid crossovers; it may well discourage physicians from geriatric 
practice and be reflected as fewer physicians who can dedicate their practice to 
health care of the elderly. Inflation of office costs coupled with further reduced 
reimbursement for medical services will make it impossible for newly established 
physicians to participate in the Medicaid Program. 

During the past months, the North Carolina Medical Society has worked closely 
with Barbara D. Matula, Director of the Division of Medical Assistance, and her 
staff in trying to face cuts in the Medicaid budget, scheduled for October 1, 1981. 
We understand the necessity for cost containment in this and all other areas of 
health care. We want to be involved in a solution to the problem, and we shall 
cooperate in every way possible. However, physicians cannot accept, with grace, 
this reduction in reimbursement which will inflate the costs of participation in 
the Medicaid Program. 

I shall appreciate :■' t greatly if you will advise how the North Carolina Medical 
Society can obtain relief from the implementation of the recent reduction in reim- 
bursement for care of the elderly, through alteration of method of payment for 
Medicare/Medicaid "crossover" claims. We are grateful for your consideration and 
advice. 



Sincerely, 



1 




Jose^ine E. Newell, M.D. 
President 



JEN/lic 











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• Softens and moistens harsh, dry toilet tissue which can 
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• Applies conveniently, and patients needn't touch 
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When significant inflammation is present 

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HEMTREX/HC® Topical Medicated Foam 
(0.5% hydrocortisone acetate, 5% benzocaine) 

HEMTREX/HC® Rectal Suppositories 

( 1 mg hydrocortisone acetate, 1 5 mg ephedrine sulfate, 

100 mg zinc oxide) 

oefore prescribing, see complete product information, 
a summary of which follows. 

Contraindications: 

Do not use HEMTREX/HC Topical Medicated Foam or 
HEMTREX/HC Rectal Suppositories in patients with tuberculo- 
sis of the skin or with a history of sensitivity to any of the com- 
ponents in the preparation. Prolonged use during pregnancy 
is contraindicated (See Precautions) 

Do not use HEMTREX/HC Rectal Suppositories in patients 
with heart disease, high blood pressure, hyperthyroidism, 
diabetes, difficulty in urination, or who are taking tranquilizers 
or nerve pills. 

Warnings: ' 

For HEMTREX/HC Topical Medicated Foam: CONTENTS I 
UNDER PRESSURE. DO NOT PUNCTURE OR INCINERATE. 

Intentional misuse by deliberately concentrating and inhaling ! 
the contents can be harmful or fatal. Do not insert any part of 

the aerosol container into the anus. Keep this and all medi- | 

cations out of the reach of children (See Precautions). i 

Precautions: 

If irritation develops, the product should be discontinued ; 
and appropriate therapy initiated. In the presence of an infec- , 
tion resistant to treatment with antifungal or antibacterial 
agents, discontinue the use of the product until the infection 
has been controlled 

Pregnancy Category C — Hydrocortisone has been shown 
to be teratogenic in mice, rats, rabbits and hamsters when 
given in doses therapeutically equivalent to dosages used 
clinically in man. Those studies did not, however, evaluate the 
effect of topically applied drug 

There are no adequate and well controlled studies in preg- 
nant women. Hydrocortisone should be used during pregnancy 
only if the potential benefit justifies the potential risk to the 
fetus. Infants born of mothers who have received substantial 
doses of corticosteroids during pregnancy should be carefully 
observed for signs of hypoadrenalism. 

Topical steroids should not be used extensively on preg- 
nant patients, in large amounts, or for prolonged periods 
of time 

Adverse Reactions: 

The following localized adverse effects, although rare, havf' 
been reported with corticosteroids, especially under occlusive 
conditions: burning, itching, irritation, dryness, folliculitis, 
hypertrichosis, acneform eruptions, hypopigmentations, 
allergic contact dermatitis, maceration of the skin, secondary 
infection, skin atrophy and miliaria. 

Dosage and Administration: 

HEMTREX/HC Rectal Suppositories: Use one suppository 
at bedtime and one in the morning. Do not use for more than 
SIX days unless directed by a physician. 

HEMTREX/HC Topical Medicated Foam: Use before and , 
after each bowel movement making certain to leave a protec- 
tive coating after cleansing Repeat when necessary to main- 
tain comfort, up to three or four times daily. Do not use for 
more than six days unless directed by a physician. i 

How Supplied: 

HEMTREX/HC Rectal Suppositories are available in boxes ; 
of 12. 

HEMTREX/HC Topical Medicated Foam is available in 1 .4 
oz (40 gm) canisters which, depending on use, contain be- 
tween 30 and 40 foam applications. Store at room tempera- 
ture— nor over 120°F. 

HEMTREX Hemorrhoidal Suppositories are available in 
boxes of 12 or 24. 

HEMTREX Hemorrhoidal Medicated Cleansing Foam is 
available in 1 .4 oz (40 gm) and 3 oz (85 gm) canisters. 

Labelling Prepared January 1981 



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For more information and a free 

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REFERRING YOUR PATIENTS 

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We are convenient to Duke Medical Center, V.A. Hospital and McPherson's Hospital. We 
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6:00p.m. Transportation after 6:00 p .m. by special request only . Via our free van service , 
we are only 7 to 8 minutes away and your parking problems are solved. 

We offer friendly, courteous service to all our guests. So often the special needs of patients 
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An ounce 
of prevention . . 

Is worth a pound of cure. 



Good advice ? You know it 
is. As a doctor, you've 
seen what prevention can 
do for people. Prevention 
is an important part of 
staying healthy. 

The same prevention can be 
applied to insurance . . . 
prevention against financial 
hardships caused by a covered 
sickness or injury that may 
keep you from your practice. 

As a member of the North 
Carolina Medical Society, you 
are eligible to apply for 
disability income protection for 
younger doctors. This plan 
can provide you with regular 
monthly benefits. 

You can use your benefits any way 
you choose — to buy groceries, 
make house payments or provide 
for your children's education. If you 
are under the age of 55 and are 
active full time in your practice, 
simply fill out the coupon below 
and return it today. Mutual of 
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will provide personal, courteous 
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Please provide me complete information on the 
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MANDALA CENTER HOSPITAL 

From time to time individuals may experience extreme problems in living. When this happens, it may 
become necessary to seek help from experienced members of the medical and helping professions. 
Mandala Center is an uncommon program dedicated to bringing to individuals an awareness of the 
source of their distress and help them find resolutions to their problems. 

Mandala Center is a JCAH accredited, private psychiatric hospital that specializes in the treatment of 
psychiatric illness, drug addiction, and alcoholism. The hospital was established in 1972 and is 
founded upon an interdisciplinary treatment approach. The 75-bed facility is located in Winston- 
Salem, NC, on a 15-acre site, and offers a full range of therapeutic modalities. Under medical 
supervision, the treatment team consists of psychiatrists, psychologists, pastoral counselors, social 
workers, psychiatric nurses, mental health workers and activities therapists. General medical care and 
special medical problems are provided for by the consulting staff. 

Adults and adolescents may enter the program which handles all categories of emotional and 
mental dysfunction. 




MEDICAL STAFF 

Bruce W- Rau, M.D., Medical Director 

Roger L. McCauley. MD 

Larry T. Burcin, M D, 

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James Mattox, MD. 

All Jarrahi, MD. 

Selwyn Rose, MD. 

Glenn N. Burgess, MD. 



MANDALA CENTER, INC. 

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For Information, please contact: 
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(jinamm" 

( nine suttate tablets) 

[ HON Federal law profiibils dispensing wilhoul prescnplion 
i F SUMMARY 

II CATIONS AND USAGE 

f ie prevention and ireatmenl ol nocturnal recumbency leg muscle cramps. 
C TRAINDICATIONS 

C JfTim may cause lelal harm when adminislered lo a pregnani woman 
C eriiiai mallormalions in the human have been reported wMh ihe use ot 
Q ne primarily with large doses (up lo 30 9 ) lor attempted abortion In aDoul 
fi )l ihese reports the maltormalion was deafness relaled lo auditory nerve 
fi oiasia Among the oiher abnormalities reported were limb anomalies, vis- 
t deteds, and visual changes in animat tests, teratogenic elfects were lound 
<f ibils and guinea pigs and were absent in mice, rals, dogs and monkeys 
imm IS conlramdicaied m women who are or may become pregnant ll ihis 
"J IS used during pregnancy, or il Ihe palient becomes pregnani while taking 
B 'rug the paiient should be apprised ol the potential hazard to Ihe (etus, 
8 jse ol Ihe gumme conient, Qumamm is contramdicated m pahenis wilh 
In quinine hypersensitivity and m patients with glucose-6-phosphate dehy- 
i^nase tG-6-PD) deficiency 

thrombocytopenic purpura may lollow (he adminislralion of quinine m 
i' sensitive pabents, a hislory of this occurrence associaled with previous 
le ingestion coniramdicales ils further use Recovery usually occurs lol- 
g withdrawal ol Ide medication and appropriate Iherapy 
'3fug should nol Be used m palienis with linnilus or opiic neuritis or in 
! lis with a history of blackwaler lever 
IINGS 

ited doses or overdosage ol qumme m some individuals may precipitate a 
'r ol Symptoms reierred to as cmchonism Such symptoms, m the mildest 
; include ringing in Ihe ears, headache, nausea, and slightly disturbed 
:>. however, when meOicalion is conimueO or after large single doses, 
'■cms also involve the gastrointestinal tract the nervous and cardiovascular 
Sy ns, and !he skin 

H* lysis (wdh the potential for hemolytic anemia) has been associated with a 
G- D deficiency in patients taking quinine Quinamm should be slopped 
!"■ Jialely if evidence ol hemolysis appears 

It iptoms occur, drug should be discontinued and supportive measures 
m- ted In case of overdosage, see OVERDOSAGE section of prescribing 
inl,.aiion 
PPlUTIONS 
fell 

(fc nm should be discontinued it there is any evidence of hypersensitivity 
(S< OMTRAlNDiCATIONS ) Cutaneous Hushing, pruritus, skin rashes, fever, 
98 distress, dyspnea, ringing in Ihe ears, and visual impaitmenl are the 
IK expressions ol hypersensitivity, particularly i! only small doses of quinine 



have been taken. Extreme flushing ot the skin accompanied by mlense. 
generalized pruritus is Ihe most common form. Hemoglobinuria and asthma 
from quinine are rare types of idiosyncrasy 

In patienis With atnal fibrillation, the administration of quinine requires the same 
precautions as those lor quinidine (See Dru g interactions ) 
D_r u q Interactions 

Increased plasma levels of digo^m and digitoxm have been demonstrated m 
individuals after concomitant quinidme administration Because ol possible simi- 
lar effects Irom use of qutmne. it is recommended that plasma levels for digoxin 
and digiloxin be determined lor those individuals taking these drugs and 
Quinamm concomitantly 

Concurrent use ol aluminum-containing antacids may delay or decrease absorp- 
tion ol quinine 

Cinchona alkaloids, including quinine, have tfie potential lo depress the hepatic 
enzyme system that synthesizes the vitamm K-dependent factors The resulting 
hypoprothrombinemic effect may enhance the action ol warfarin and other oral 
anticoagulants 

The etiecis ol neuromuscular blocking agents (particularly pancuronium suc- 
cmylchotme and tubocuranne) may be potentiated with qumme. and result m 
respiratory difficulties 

Urinary aikalizers (such as acelazoiamide and sodium bicarbonate) may increase 
qumme blood levels wilh potential lor toxicity 
Drug Laborator y Interactions 

Quinine may produce an elevated value lor urinary 17-ketogenic steroids when 
the Zimmerman method is used 
Carcino g enesis , Muta g enesis im pairment of Fertilit y 
A sludy ol quinme sulfate administered in drinking water (0 fo) to rats for 
periods up to 20 months showed no evidence of neoplastic changes 
Mutation studies ol qumme (dihydrochlonde) m male and female mice gave 
negative results by the micfonucleus test Intraperitoneal miections (0 5 mM 
kg ) were given twice. 24 fiours apart Direct Salmonella lyphimunum tests 
were negative, when mammalian liver hemogenale was added, positive results 
were lound 

No inlormation relating to the eflecl ol qumme upon lertility m ammal or m man 
has been found 
Preg nanc y 

Category X See CONTRAINDICATIONS 
Nonlerato q emc Effects 

Because qumme crosses the placenta m humans. Ihe polenlial for lelal effects is 
present Stillbirths m mothers taking qumme have been reported m which no 
obvious cause for the tetai deaths was shown Qumme m loxtc amounts has been 
associated with abortion Whether ifiis action is always due to direct elfecl on the 
uterus IS questionable 
Nursin g Mothers 

Caution should be exercised when Qumamm is given to nursing women because 
qumme is excreted m breast milk (m small amounts) 



ADVERSE REACTIONS 

The loHowmg adverse reactions have been reported with Qumamm m therapeutic 
or excessive dosage (individual or multiple symptoms may represent cm- 
chonism or hypersensitivity ) 

Hematologic acute hemolysis thrombocytopenic purpu'a. agranulocytosis, 
hypoprothfombmemia 

CA/S visual disturbances including blurred vision with scotomaia photophobia, 
diplopia diminished visual lields and disturbed color vision immtus, deafness 
and vertigo, headache, nausea, vomiting, fever apprehension restlessness, 
contusion, and syncope 

Defmaioiogic allergic cutaneous rashes (urticarial ihe most frequent type ol 
allergic reaction papular, or scarlatinal), pruritus. Hushing of the shm sweating, 
occasional edema ol the face 
Respiratory asthmatic symptoms 
CsrOiovascular anginal symptoms 

Gasifoiryfestmal nausea and vomiimg (may be CNS-ceialed). epigastric pain 
□RUG ABUSE AND DEPENDENCE 

Tolerance abuse or dependence wilfi Qumamm has not been reported 
OVERDOSAGE 

See piesc'ibmg mtormaiion lor a discussion on symptoms and treatment of 
overdose 

DOSAGE AND ADMINISTRATION 

1 tablet upon retiring II needed, 2 taOiels may be tahen mghtiy — I lollowmg the 
evening meat and 1 upon retiring 

Aftei several consecutive nights m which recumbency leg cramps do not occur, 
Qumamm may be discontinued m order to determine whether continued therapy 
IS needed 

Product Information as of October. 1980 

Licensor of Merrell' 

MERRELL-NATIONAL LABORATORIES Inc 
Cayey Puerto Rico 00633 



Direct Medical Inquiries to 

Merrell 



MERRELL DOW PHARN4ACEUTICALS INC. 

Subsidiary of The Dow Chemical Company 

Cinannati. OH 4521 5 , U.S.A. 



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Each gram contains: Aerosporins (Polymyxin B Sulfate! 5,000 units, bacitracin zinc 400 units, neomycin sulfate 5 mg 
(equivalent to 3.5 mg neomycin base); special white petrolatum qs; in tubes ofl ozand 1/2 oz and 1/32 oz (appro.x.) foil packets. 

works just as well in their homes. 



• It's effective therapy for 
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(polymyxin B bacitracin- neomycin) 

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petrolatum qs: in tubes of 1 ozand 1/2 ozand 1/32 oz 
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where more than 20 percent of the body surface is 
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biotics concurrently, not more than one application a 
day is recommended. 



When using neomycin-containing products to control 
secondary infection in the chronic dermatoses, it 
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ADVERSE REACTIONS: Neomycin is a no 
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Burroughs Wellcome Co. 

Research Triangle Park 
North Carolina 27709 



The Diminishing Mortality 

of Coronary Artery Bypass Grafting 

For IVIyocardial Ischemia 



Robert N. Jones, M.D., Steven E. Curtis, Andrew S. Wechsler, M.D., W. Glenn Young, Jr., M.D., 

H. Newland Oldham, Jr., M.D., Walter G. Wolfe, M.D., Robert Whalen, M.D., James J. Morris, M.D., 

Walter L. Floyd, M.D., and David C. Sabiston, Jr., M.D. 



ABSTRACT The operative mor- 
tality associated with coronary ar- 
tery bypass procedures has declined 
impressively in recent years. Two 
groups of patients undergoing coro- 
nary grafting at the Duke University 
Medical Center were analyzed retro- 
spectively: Group I was comprised of 
200 consecutive patients operated 
upon between 1974 and 1976, and 
Group II consisted of 200 consecutive 
patients undergoing coronary graft- 
ing between 1978 and 1979. Since 
1976 the operative mortality for this 
procedure has diminished appreci- 
ably, and for the patients in Group II 
was 0.5%. Reasons for the decline in 
operative mortality include im- 
proved techniques in myocardial 
preservation, more extensive graft- 
ing of involved coronary arteries, 
improved anesthetic management, 
and advances in surgical techniques 
and postoperative care. 

INTRODUCTION 

NEARLY two decades have 
passed since the first attempts 
to directly revascularize the myo- 
cardium of patients with ischemic 
coronary artery disease. '^^ Since 
then, coronary artery bypass graft- 
ing (CABG) has emerged both as an 



From the Duke University Medical Center 
Durham. North Carolina 27710 



effective modality for relieving the 
symptoms of ischemic heart dis- 
ease^" and as a method of improving 
survival in certain groups with 
coronary disease/"^ The number of 
patients to undergo such proce- 
dures has increased each year, and 
more than 100,000 persons in the 
United States alone are expected to 
receive coronary grafts this year. 

A significant factor in the im- 
proved results of CABG has been a 
clearer understanding of peri- 
operative ischemic myocardial in- 
jury. In the earlier experience with 
CABG, the obvious technical ad- 
vantage of operating on a motion- 
less heart in a bloodless operative 
field was recognized. It is now well 
understood, however, that nor- 
inothermic ischemic arrest has a 
very unfavorable effect on cardiac 
metabolism. Recognition of this fact 
led clinical and experimental inves- 
tigators throughout the world to 
seek improved techniques for main- 
taining the metabolic integrity of the 
heart during intraoperative cardiac 
arrest.'" The recent, nearly univer- 
sal acceptance of cold potassium ar- 
rest to protect the ischemic inyo- 
cardium attests to the influence of 
these investigators. 

Cold potassium cardioplegia was 
introduced at Duke University 
Medical Center as an adjunct to 



September 1981, NCMJ 



CABG in 1976. Since then we have 
noted a gratifying decline in the 
operative mortality for myocardial re- 
vascularization procedures. While 
improved myocardial protection 
has contributed to this decline, 
other significant factors have been 
involved as well. A greater under- 
standing of the various physiologic 
principles which govern the energy 
needs of the heart, particularly in 
the presence of diseased vessels, 
has led to a broader approach that 
includes improvements in anes- 
thetic management and in the tech- 
niques of cardiopulmonary bypass. 
The purpose of this study is to com- 
pare the results of current tech- 
niques used in CABG in one institu- 
tion with the results of approaches 
used before the introduction of cold 
potassium cardioplegia and the 
other techniques in current use. 

MATERIAL AND METHODS 

Clinical Data 

The data were obtained from the 
records of patients who underwent 
CABG for chronically disabling or 
unstable angina at Duke University 
Medical Center. Group I is com- 
prised of 200 consecutive patients 
operated upon between July 1974 
and October 1976, immediately be- 
fore the introduction of potassium 

637 



cardioplegia. Tlie patients in Group 
II consist of 200 consecutive pa- 
tients undergoing CABG between 
December 1978 and December 
1979. In both groups, patients who 
underwent concomitant valvular 
replacement or ventricular aneu- 
rysmectomy were excluded. 

Surgical Management 

Patients in Group I underwent 
CABG employing one of three 
techniques. In most, autogenous 
saphenous veins were anastomosed 
to the ascending aorta either before 
cardiopulmonary bypass or during 
the initial phases of bypass with a 
partial occlusion clamp. Distal 
anastomoses were then made using 
either (1) intermittent ischemia, (2) 
continuous ischemia, or (3) con- 
stant perfusion and induced ven- 
tricular fibrillation. In each patient 
the body temperature was main- 
tained between 28° and 32°C by 
extracorporeal circulation. 

The vast majority of the patients 
in Group II received cold potassium 
cardioplegia and topical hypother- 
mia during coronary artery anas- 
tomoses. The composition of the 
cardioplegic solution used is shown 
in Figure 1 , with the pH being de- 
pendent on the temperature at 
which the solution is administered. 
The proximal coronary anastomo- 
ses were made as previously de- 
scribed. For the distal anastomoses 
the ascending aorta was occluded, 
and 500 to 700 ml of potassium car- 
dioplegic solution was infused at 
4°C into the aortic root producing 
almost immediate cardiac arrest and 
a reduction in the myocardial tem- 
perature to approximately 10°. 
During ischemic arrest, most of the 
patients received additional solu- 
tion every 15 to 20 minutes in order 
to maintain the myocardial temper- 
ature at low levels and to assure 
complete pharmacologic cardiac ar- 
rest. The reason for repetitive infu- 
sions of cold potassium solution is 



Na* 


147 mEq/L 


Cl- 


155.5 mEq/L 


K+ 


24-34 mEq/L 


Ca+ 


4.5 mEq/L 


CHO 


5% 


pH' 


5.0-75 


Osm 


309 mOsm/L 



Fig. 1. The composition of the cardioplegic 
solution. 



638 



to offset the effect of the non-coro- 
nary collateral blood flow which 
tends to rewarm the ischemic myo- 
cardium and wash out intracoro- 
nary cardioplegic solution. During 
the final distal anastomosis, the 
systemic temperature is gradually 
increased to 37°C and the heart is 
allowed to rewarm. 

Some of the patients in Group II 
underwent CABG with topical 
hypothermia alone and others with 
cardioplegic solution alone. Topical 
hypothermia is produced by im- 
mersing the heart in cold (4°) physi- 
ologic saline placed in the pericar- 
dial sac. A small number of opera- 
tions in Group II were performed 
without cardiopulmonary bypass or 
in one of the manners described in 
Group I. 

In both the groups cardiopulmo- 
nary bypass utilizing a disposable 
bubble oxygenator was used with a 
right atrial cannula for venous 
drainage and an ascending aortic 
cannula for arterial perfusion. Ap- 
proximately 75% of Group I pa- 
tients had left ventricular venting of 
some form while the majority of 
Group II patients were not vented. 

Inlra-aortic Balloon Pumping (lABP) 
and Pulsatile Bypass Pump (PBP) 

lABP may be used to assist in 
weaning the patient from cardio- 
pulmonary bypass. It has also been 
used prior to operation in those with 
poor left ventricular function. The 
rationale for using the lABP is its 
ability to reduce systemic afterload 
and augment diastolic coronary 
arterial driving pressure. In Group 
II the pulsatile bypass pump was 
frequently employed. During extra- 
corporeal circulation the PBP pro- 
vides pulsatile flow, which many 
believe is preferable to the usual 
mean flow pattern of the bypass 
pump. The PBP can also be used 
before and after CPB to augment 
diastolic pressure. 

Postoperative electrocardiogram 

In the two groups, the postopera- 
tive development of new, signifi- 
cant Q waves (greater than .04 sec.) 
was considered suggestive evidence 
for myocardial infarction. Post- 
operative EKGs were examined for 



Table 1: 


Functional Status of Patients* 


Class 


Group 1 


Group II 




(No. Patients) 


(No. Patients) 


1 


11 (5.5%) 


4 (2%) 


II 


13(6.5%) 


26 (13%) 


III 


46 (23%) 


60 (30%) 


IV 


130 (65%) 
Heart Association Class 


110 (55%) 


■New York 


fication for angina 


pectoris 







atrial arrhythmias, intraventricular 
conduction defects, and ischemic 
changes by a cardiologist unaware 
of the conduct of the operation or 
the recovery period. The data are 
expressed as mean ± standard de- 
viation, or as percentage of the total 
number of patients within each 
group. 

RESULTS 

Preoperative Assessment 

Sex and age. In both groups there 
were 165 males and 35 females. The 
mean age for Group I was 50.5 years 
(range 26-66), and for Group II it 
was 53.5 years (range, 20-70). 

Operative status. In Group I, 186 
patients (93%) underwent operation 
on an elective basis and 14 patients 
(7%) received emergency CABGS. 
In Group II, 158 patients (79%) were 
operated upon electively, and 42 
patients (21%) on an emergency 
basis. The emergency group was 
comprised of patients with unstable 
angina or lesions such as left main 
disease, for whom it was advisable 
to proceed promptly with opera- 
tion. 



Table II 




Data Obtained From 
Cardiac Catheterization 




Group 1 

(No. 
Patients) 


Group II 

(No. 
Patients) 


Number Diseased Vessels 

1 
2 
3 


1 (.5%) 
40 (20%) 
56 (28%) 
103(51.5%) 


2 (1%) 
31 (16%) 
78 (39%) 
89 (44%) 


Left Main Disease 
Subtotal (75-95%) 
Total (100%) 


23(11.5%) 
2 (.196) 


23(11.5%) 



Ejection Fraction 
< 25% 
25-40% 
46-60% 
> 60% 


4 (2%) 
40 (22%) 
85 (48%) 
49 (28%) 



40 (23%) 
89 (50%) 
48 (27%) 


Left Ventricular 
End Diastolic 
Pressure > 18 mm Hg 


15 (7.5%) 


39 (19.5%) 




Vol 


42, No. 9 



Table III: 


Techniques 


Of Coronary 


Artery Byp 


ass Surgery 










Ischemic 


Reper- 


Length 


Mode ol Myocardial 




Total 


Time 


fusion 


of 


Protection 


n 


Ischemia 


Per Graft 


Time 


CPB 






(MIns.) 


(MIns.) 


(MIns.) 


(MIns.) 


Group 1 












Intermittent reperfusion 


56 pts (28%) 


27.2 ± 13.6 


12.53 I 5.26 


31.7 ± 20 


102.9 » 39.5 


Moderate tiypothermia and 












single ischemic interval 


54 pts (27%) 


21 87 ± 18.91 


11.01 ± 7 91 


30.54 ± 23.28 


94 33 ± 43 


Ventricular fibrillation 


90 pts (45%) 








63.9 ± 34 5 


Group II 












Cardioplegia and topical 












hypothermia 


171 pts (85.5%) 


46.78 ± 25.63 


17.36 ± 7.9 


29.9 ± 20.2 


99 4 ± 43 


Cardioplegia alone 


10 pts (5%) 


38.5 ± 20.8 


21.75 ± 12.8 


16.3 ± 7.21 


75.5 ± 42.3 


Topical hypothermia alone 


3 pts (1.5%) 


16.6 ± 3 


6.4 ± 1.7 


38.6 i 8 


116 ± 11-6 


Moderate hypothermia and 












single ischemic interval 


6 pts (3%) 


7,7 ± 3 


4.9 ± 2.2 


37.2 ± 25 


69.3 ± 40 


Intermittent reperfusion 












and topical hypothermia 


4 pts (2%) 


29.5 I 4 


9.8 ± 1.2 


49.2 ± 10 


1275 ± 21.8 


Without cardiopulmonary 












bypass 


5 pts (2.5%) 










Ventricular fibrillation 


1 pt (.5%) 











Angina pectoris. In Table I, the 
patients in both groups are catego- 
rized according to the New York 
Heart Association Classification for 
angina. Six patients (3%) in Group I 
and 10 (5%) in Group II had previ- 
ous histories of congestive heart 
failure. 

Cardiac Catherization and An- 
giography. The results of cardiac 
catheterization are shown in Table 
II. The average number of diseased 
vessels in Group I was 2.3 ± .8 and 
in Group II it was 2.3 ± .8. The 
values for preoperative ejection 
fractions and left ventricular end 
diastolic pressure (LVEDP) are 
listed for the 178 patients in Group I 
and the 177 in Group II in whom 
such data were obtained. As is ap- 
parent, both groups were similar in 
terms of the preoperative ejection 
fractions and number of diseased 
vessels. Also, the degree of left 
main disease was similar in both 
groups. The significantly larger 
number of individuals with an 
LVEDP greater than 18 in Group II, 
however, suggests that there were 
more patients with poorly func- 
tioning ventricles in this group. 

Preoperative EKG Evidence of 
Myocardial Infarction. Sixty-nine 
patients (34.5%) in Group I and 72 
patients (36%) in Group II had elec- 
trocardiographic evidence of a pre- 
vious myocardial infarction. One 
patient in Group I and six in Group 
II had preoperative intraventricular 
conduction defects. 



Operative Assessment 

Myocardial Protection. The tech- 
niques by which CABG was per- 
formed are shown in Table III. 

Completeness of Revasculariza- 
tion. The mean number of grafts in 
Group I was 2.0 ± .8, and that for 
Group II was 2.6 ± .9. The number 
of patients who received fewer 
grafts than diseased vessels (com- 
pleteness of revascularization) was 
65 (32.5%) in Group I and 17 (8.5%) 
in Group II. 

Intra-aortic Balloon Pumping and 
Pulsatile Bypass Pump. The use of 
the lABP has diminished since 1974. 
InGroupI,31 patients (15.5%) were 
placed on lABP while in Group II 
only 15 patients (7.5%) had lABP. 
By contrast, there were no patients 
in Group I who were placed on the 
PBP. while 42% (84 patients) of 
Group II received the PBP. 

Operative Mortality. The number 
of patients who died in both groups 



and the manner in which they were 
managed during the operation are 
shown in Table IV. In Group I, 12 
patients died intraoperatively and 
six died within 30 days. Sixteen of 
these patients died of cardiac prob- 
lems. There was only one death in 
Group II — an operative mortality 
of 0.5%. This patient died of a car- 
diac arrhythmia on the third post- 
operative day. 

Postoperative Assessment 

Surgical Complications. The 

postoperative complications in both 
groups are depicted in Table V. The 
incidence of postcardiotomy syn- 
drome (chest pain, pericardial rub, 
and fever) has diminished in the re- 
cent past. 

Postoperative Electrocardiogram. 
Seventeen patients (8.5%) in Group 
I and 18 patients (9%) in Group II 
developed significant Q waves post- 
operatively. Of note is that more pa- 
tients developed intraventricular 
conduction defects of some type in 
Group II, 96% of whom received 
potassium cardioplegia. Most of 
these EKG changes were transient, 
resolving within three days, and 
were generally of little clinical sig- 
nificance. 

DISCUSSION 

The operative mortality for 
CABG has progressively dimin- 



Table V 
Postoperative Complications 

Group I Group II 

(No. Patients) (No. Patients) 

Superficial Wound 2 (1%) 

Low Cardiac Output 1 (.5%) 1 (.5%) 

Hemorrhage 8 (4%) 4 (2%) 

Mediastinitis 1 (.5%) 2 (1%) 

Post Card Synd. 26(13%) 9(4 5%) 

Rectus Hematoma 2 (1%) 



Table IV: Operative Mortality 



Group I 

Intraoperative 

Postoperative 

Total 

Group II 
Intraoperative 
Postoperative 
Total 





Moderate 








Hypothermia and 






Intermittent 


Single Ischemic 


Ventricular 


Cold 


Ischemia 


Interval 


Fibrillation 


Cardloplegi 


(Patients) 


(Patients) 


(Patients) 


(Patients) 


2 


S 


5 


— 


2 


1 


3 


— 



18(9%) 





1 

1 (.5%) 



September 1981, NCMJ 



639 



ished and many centers now report 
rates of less than 3%."'''' Many 
ascribe this low surgical mortality to 
the recent use of improved myocar- 
dial protection, more complete re- 
vascularization, better anesthetic 
techniques and more effective post- 
operative management. The experi- 
ence reported in the present study 
tends to support this. The 0.59r 
mortality in the 200 patients in 
Group II is most likely the result of a 
number of inter-related factors. 

One important feature concerns 
the possibility that improvement in 
patient selection has reduced 
operative mortality. While it is pos- 
sible that fewer patients in Group II 
succumbed acutely because pre- 
operative ventricular function was 
better and coronary arterial disease 
was less extensive, analysis of our 
data does not support this sugges- 
tion. Operative mortality has gener- 
ally correlated directly with a pre- 
operative LVEDP greater than 18 
mm Hg, abnormalities in left ven- 
tricular wall-motion, and ejection 
fractions less than 25 to 30%. '-■-'■' In 
Groups I and II the distribution of 
patients with 2 and 3 vessel disease, 
preoperative ejection fractions (less 
than 40%), and the number of pa- 
tients in NYHA Class III and IV 
were similar and does not indicate 
that patients currently undergoing 
CABG are significantly different 
than previously. In fact, with a 
greater number of patients with an 
LVEDP greater than 18 in Group II. 
it appears that the later group in- 
cludes sicker patients. 

It appears that hypothermic solu- 
tions containing moderate concen- 
trations of potassium (20-30 mEq/ 
liter) extend the ischemic tolerance 
time of the myocardium.-""-^ Dur- 
ing ischemia the demand for energy 
by the myocardium is primarily 
determined by its continued elec- 
tromechanical activity, basal meta- 
bolic functions and temperature. By 
producing immediate electrome- 
chanical cardiac arrest and main- 
taining the heart at temperatures 
between 12° and 15° C, cold potas- 
sium arrest leads to a decrease in 
utilization of high energy phosphate 
during ischemia.-'^ -" Although the 
primary reason for adenosine tri- 
phosphate (ATP) depletion during 



ischemia is continued electrome- 
chanical activity,-'* hypothermia is 
also critical in reducing utilization 
of ATP by slowing all intracellular 
metabolic processes and thereby 
forestalling significant ischemic in- 
jury.-" The ischemic interval not- 
withstanding, the reperfusion phase 
is important in determining the ul- 
timate state of the previous is- 
chemic myocardium.''" ■'- In con- 
trast to normothermic ischemia, 
blood flow in hearts arrested with 
potassium and kept cold during is- 
chemia is redistributed toward the 
subendocardium.-" Ventricular 
compliance and overall ventricular 
performance, moreover, are also 
not affected when hearts are made 
ischemic with cold pharmacologic 
arrest.-'-' 

In contrast, earlier use of inter- 
mittent coronary reperfusion during 
ischemia to repay metabolic debt 
has been associated with deteriora- 
tion in ventricular compliance as 
well as maldistribution of flow with 
underperfusion of the subendocar- 
dium.-'^ -'" Of the 56 patients in 
Group I whose hearts were ren- 
dered intermittently ischemic, four 
died. That induced ventricular fib- 
rillation exerts an adverse effect 
upon the heart is suggested by the 
eight deaths among those patients 
so treated. That fibrillation may 
create similar flow imbalances and 
be associated with subendocardial 
necrosis, especially in hypertro- 
phied hearts, ''"^" has led to striking 
restriction of its use. In addition, 
there were 54 patients in Group I 
who underwent CABG during a 
single ischemic interval under con- 
ditions of moderate hypothermia 
(28° to 32° C). It is now recognized 
that metabolic deterioration during 
ischemia is not only related to time 
but to temperature as well, and that 
deeper hypothermia provides addi- 
tional protection from severe irre- 
versible injury. ^'■^- 

The different approaches for 
protecting the heart during CABG 
which were formerly used and con- 
sidered effective have been re- 
placed by sounder methods of myo- 
cardial preservation, while changes 
in perioperative anesthetic man- 
agement have been significant in re- 
ducing operative mortality, as in- 



stanced by the current practice of 
preventing fluctuations in blood 
pressure of more than 20% of nor- 
mal. The use of the Swan-Ganz 
catheter to monitor left as well as 
right heart pressures throughout the 
operation has also been effective in 
providing hemodynamic data upon 
which more appropriate therapeutic 
decisions can be made. 

Advancements in anesthetic man- 
agement parallel the improvements in 
operative skill brought about by a 
greater experience." A committed 
effort to bypass all significant 
lesions is illustrated in the present 
series by the fewer patients receiv- 
ing incomplete grafting (9% in 
Group II vs. 32% in Group I). The 
completeness of revascularizing 
significantly obstructed vessels, in- 
cluding branches of the major coro- 
nary arteries, is important and has 
been clearly related to the decline in 
operative mortality. '"-^^ 

The relationship of pulsatile per- 
fusion during cardiopulmonary by- 
pass to operative mortality and 
morbidity is actively debated. The 
ability of the PBP to improve hemo- 
dynamics in a patient with a com- 
promised ventricle is supported by 
early work with the intra-aortic 
balloon pump. Following cardio- 
pulmonary bypass I ABP can reduce 
afterload and increase diastolic 
coronary flow. The effects of re- 
ducing metabolic demand while in- 
creasing coronary flow are bene- 
ficial particularly to those regions of 
the heart supplied by stenotic or ob- 
structed vessels. The effect of a pul- 
satile arterial pressure on renal and 
other vital organ functions awaits 
further study of its role in improving 
surgical results. ^■''■^'' 

In our series postoperative mor- 
bidity was minimal in both groups. 
Of much interest is the strikingly 
greater number of patients in Group 
II who developed intraventricular 
conduction defects. Recent evi- 
dence suggests that the use of po- 
tassium to protect the ischemic 
heart is related to the appearance of 
these changes." Fortunately, most 
of these alterations in conduction 
were transient and did not appear to 
retard postoperative recovery. The 
use of cold cardioplegia, moreover, 
has not been associated with de- 



640 



Vol. 42, No. 9 



terioration in myocardial function in 
patients restudied 6 to 18 months 
after surgery."*^ 

The use of hypothermia and 
pharmacologic cardiac arrest to 
protect the ischemic heart has been 
important in making CABG as safe 
as many other less complicated 
major surgical procedures. These 
techniques should be considered 
within the context of the expanding 
role of CABG in the management of 
coronary artery disease. The ulti- 
mate aim of myocardial revascular- 
ization includes longer life for the 
patient with ischemic heart disease 
as well as relief of symptoms. With 
the marked reduction in immediate 
mortality and morbidity in such pa- 
tients, improved survival in certain 
high risk patients has been ob- 
served. 



References 



1. Sabiston DC Jr: The coronary circulation Johns Hop- 
kins Med J 134:329. 1974. 

2. Effler DB. Groves LK. Sones FM Jr. Shirey EK: En- 
darterectomy in the treatment of coronary artery dis- 
ease. J Thorac Cardiovasc Surg 47:98-108. 1964. 

3. Connolly JE. Eldndge FL. Calvm JW. Stemmer EA: 
ProximaJ coronary artery obstruction: its etiology and 
treatment by transaortic endarterectomy, N Engl J Med 
271:213-219. 1964. 

4. Garrett HE, Dennis EW, DeBakey ME: Aortocoronary 
bypass with saphenous vein graft. JAMA 223:792-794. 
1973. 

5. Mathur VS. Guinn GA: Prospective randomized study 
of coronary bypass surgery in stable angina: the first 100 
patients. Circulation 51-52(1): 133. 1975. 

6. Peduzzi P. Hultgren H: Effect of medical vs surgical 
treatment on symptoms in stable angina pectoris: the 
Veterans Administration cooperative study of surgery 
for coronary arterial occlusive disease. Circulation 
60:888-900. 1979. 

7. Stiles Q. Lindesmith GC. Tucker BL. et al: Long term 
follow upof patients with coronary artery bypass grafts. 
Circulation 54(III):32-34, 1976. 

8. TakaroT. Hultgren HN, Lipton MJ. Detre K: The VA 
cooperative randomized study of surgery for coronary 



occlusive disease: subgroup with significant left main 
disease. Circulation 54(1111:107-1 17. 1976. 
9. VA cooperative study group for surgery for coronary 
arterial occlusive disease: use of noninvasive clinical 
parameters with angina pectoris, treated medically and 
surgically Am J Cardiol 45:456. 1980. 

10. Miller DW. Hessel EA. Winterschied LR. et al: Current 
practice of coronary artery bypass surgery: results of a 
national survey. J Thorac Cardiovasc Surg 73:75. 1977. 

1 1 . Cameron A. Kemp KG. Shimomura S. et al: Coronary 
artery bypass surgery: a seven year follow-up. Circula- 
tion 57-58:11-19. 1978. 

12. Kouchoukos NT. Oberman A. Kirklin JW. etal: Coro- 
nary bypass surgery, analysis of factors affecting hos- 
pital mortality. Circulation 59-60: 11-58. 1979. 

13. Greene DG. Bunnell IL, Arani DT, et al: Survival of 
selected subsets after coronary bypass surgery. Circu- 
lation 59-60: 11-58, 1979. 

14. Manley JC, Johnson WD: Effects of surgery on angina 
(pre- and postinfarction) and myocardial function (fail- 
ure). Circulation 46:1208-1221. 1972. 

15. Collins JJ, Cohn LH. Sonnenblick EH. et al: Determin- 
ants of survival after coronary artery bypass surgery. 
Circulation 48(110:132-136, 1973. 

16. Kay JH. Redington JV. Mendez AM, et al: Coronary 
artery surgery for the patient with impaired left ven- 
tncular function. Circulation 46:11-49. 1972. 

17. Oldham HN Jr, Kong Y. Bartel AG. et al: Risk factors in 
coronary artery bypass surgery. Arch Surg 105:918-923, 
1972. 

18 Hammond GL. Poirer RA: Early and late results of 
direct coronary reconstructive surgery for angina. 
J Thorac Cardiovasc Surg 65:127-133, 1972, 

19. Ruel GJ, Morris GC. Howell JF. et al: E.xperience with 
coronary artery bypass grafts in the treatment of coro- 
nary artery disease. Surgery 71:586-593. 1972. 

20. Gay WA. Ebert PA: Functional, metabolic and mor- 
phologic effects of potassium induced cardioplegia. 
Surgery 74:284-290. 1973. 

21. Craver JM. Sams AB, Hatcher CR: Potassium-induced 
cardioplegia: additive protection against ischemic myo- 
cardial injury during coronary revascularization. 
J Thorac Cardiovasc Surg 76:24-27, 1978. 

22. Gay WA: Potassium-induced cardioplegia. Ann Thorac 
Surg 20:95-100. 1975. 

23. Reitz. BA. Brody WR, Hickey PR. Michaelis LL: Pro- 
tection of the heart for 24 hours with intracellular (high 
K*) solution and hypothermia. Surg Forum 25:149-151, 
1974, 

24. Sink JD, Pellom GL. Currie WD, et al: Protection of 
mitochondrial function during ischemia by potassium 
cardioplegia: correlation with ischemic contracture. 
Circulation 60:1-158-163, 1977. 

25. Roe RB, Hutchinson JC. Fishman NH. et al: Myocar- 
dial protection with cold, ischemic potassium induced 
cardioplegia. J Thorac Cardiovasc Surg 73:366-374. 
1977, 

26. Hearse DJ. Stewart DA. Braimbndge MV: Hypother- 
mic arrest and potassium arrest: metabolic and myocar- 
dial protection during elective cardiac arrest. Circ Res 
36:481-489. 1975, 

27. Brelschneider HJ: Uberlebenszeit und wieder- 
belebungs zeil des herzens bei normo-und hypothermie. 
Verb Dtsch Ges Kreislaufforsch 30:11-34. 1964. 

28. Goldstein SM. Nelson RL. McConnell DM. Buckberg 
GD: Effects of conventional hypothermic ischemic ar- 
rest and pharmacological arrest on myocardial supply 
demand balance during aortic cross-clamping. Ann 
Thorac Surg 23:520-528. 1977. 

29. Jones RN. Hill ML, Reimer KA, et ai: Effects of 
hypothermia on the rate of myocardial ATPand adenine 



nucleotide degradation in total ischemia. Fed Proc 39: 
III. 1980. 

30. Vary TC, Angelakos ET. Schaffer S: Relationship be- 
tween adenine nucleotide metabolism and irreversible 
ischemic tissue damage in isolated perfused rat heart, 
Circ Res 45:218-225. 1979. 

31. Reimer KA. Hill ML. Jennings RB: ATP and adenine 
nucleotide resynthesis following episodes of reversible 
myocardial ischemic injury. Fed Proc 39:111. 1980. 

32. BittarN. KokeJR. Berkoff HA. Kahn DR: Histochemi- 
cal and structural changes m human myocardial cells 
after cardiopulmonary bypass. Circulation 51-52:1- 
16-25, 1975. 

33. Olsen CO, Hill RC. Jones RN. el al: Dimensional 
analysis of left ventricular systolic and diastolic 
properties in man during reperfusion following 
hypothermic potassium cardioplegia. Surg Forum 1980 
(In Press). 

34. Chilwood WR Jr. Hill RC. Kleinman LH. Wechsler AS: 
The effects of intermittent ischemic arrest on the perfu- 
sion of myocardium supplied by collateral coronary ar- 
teries. Ann Thorac Surg 26:535-547. 1978. 

35. Chitwood WR. Hill RC. Sink JD, et al: Assessment of 
ventricular diastolic properties and systolic function in 
man with sonomicrometry. Surg Forum 30:266-268. 
1979, 

36. Hill RC, Chitwood WR Jr. Kleinman LH, Wechsler AS: 
Compressive forces of fibrillation in normal hearts dur- 
ing maximal coronary dilation by adenosine, Surg 
Forum 28:257. 1977. 

37. Kleinman LH. Wechsler AS: Pressure flow charac- 
teristics of coronary collateral circulation during car- 
diopulmonary bypass: effectsof ventricular fibrillation. 
Circulation 58:233. 1978. 

38. Hottenroit CE. Towers B. Kurkji HJ: The hazard of 
ventricular fibrillation in hypertrophied ventricles dur- 
ing cardiopulmonary bypass. J Thorac Cardiovasc Surg 
66:742, 1973. 

39. Buckberg GD. Fixler DE, Archie JP: Experimental 
subendocardial ischemia in dogs with normaJ coronary 
arteries. Circ Res 30:67. 1972, 

40. Tyers GEO: Evidence for a safe myocardial hypother- 
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sented at Symposium on Myocardial Preservation. New 
York. NY,. June 1979. 

41. Angell WW, Rikkers L. Dong E, Shumway N: Organ 
viability with hypothermia. J Thorac Cardiovasc Surg 
58:619-624. 1969. 

42. Hutchinson JE. Green GE. Medhjian HA. Kemp HG: 
Coronary bypass grafting in 376 consecutive patients 
with three operative deaths. J Thorac Cardiovasc Surg 
67:7-16, 1974. 

43. Loop ED, Cosgrove DM. Lytle BW. et al: An 1 1-year 
evolution of coronary arterial surgery. Ann Surg 
190:444-445. 1979. 

44. Many M.SoroffHS, Birtwell WC: The physiologic role 
of pulsatile and nonpulsatile blood flow. Arch Surg 
97:917-923. I%8. 

45. Sink JD. Chitwood WR, Hill RC. Wechsler AS: Com- 
parison of nonpulsatile and pulsatile extracorporeal cir- 
culation on renal cortical blood flow. Ann Thorac Surg 
29:57-62. 1980. 

46. Ellis R. Mavroudis C. Ullyot D. et al: Relationship 
between artio-ventricular arrhythmias and the concen- 
tration of K" ion in cardioplegia solution. Presented at 
the annual meeting of the Amencan .Association for 
Thoracic Surgery, 1980. 

47. Ellis RJ, Gertz EW. Wisneski J. Ebert P; Analysis of 
myocardial function following potassium cardioplegia. 
Presented at the Symposium on Myocardial Preserva- 
tion. New York, N.Y.. June 1979. 



SEPTEMBER 1981, NCMJ 



641 



Neonatal Cerebral Ultrasonography 



Ewell S. Roach, M.D., Richard L. Weaver. M.D., and 
William T. McLean, M.D. 



ABSTRACT Ultrasonic scanning 
is a valuable new technique for dem- 
onstrating the intracranial anatomy 
of the neonate. Ventricles and other 
fluid filled cavities are especially well 
seen. The absence of any known risk 
of the procedure permits serial scan- 
ning in the neonatal unit, which 
might lead to earlier diagnosis of 
neurological disorders and better 
assessment of their treatment. Pre- 
liminary findings are discussed to 
demonstrate the usefulness of the 
technique. 

SEVERAL recent reports have 
shown the feasibility of demon- 
strating the intracranial anatomy of 
neonates by ultrasonic scanning.'"' 
Ultrasound has been widely used in 
diagnosing cardiac, abdominal and 
antenatal disorders, but poor pene- 
tration of the skull by sound waves 
has limited its use in detecting in- 
tracranial structures. This problem 
is avoided in neonates by the rela- 
tive lack of mineralization of the 
bony calvarium and the open fon- 
tanels. The ultrasound technique 
has been reliable in defining some 
parts of the neonatal brain, espe- 
cially the size of the ventricular 
system.^ ■' 

Our purpose is to acquaint the 
reader with a method of sonogra- 
phic brain scanning and to discuss 
its potential value in neonatal 



From the Department of Pediatrics and the Section on 

Pediatric Neurology 

Bowman Gray School of Medicine 

300 S Hawthorne Road 

Winston-Salem, N.C- 27103 

Reprint requests to Dr. Roach 



neurology. Preliminary results 
using this method have been very 
encouraging. 

METHODS 

The real-time scanner (ADR 
Model 2130) is mounted on a cart 
along with a videotape recorder, os- 
cilloscope screen, coupling gel and 
transducer probes of various fre- 
quencies. The cart arrangement al- 
lows the equipment to be moved 
easily to the nursery, where the 
scans can be performed in the crib 
or isolette with minimal disruption 
in the infant's care. 

Transducers of 3.5. 5.0, and 7.0 
MHz frequencies are tried initially 
and the transducer with the sharpest 
image reproduction is then selected 
for use. Generally, the 7.0 MHz 
transducer works best when scan- 
ning tiny premature infants or in- 
fants of any gestational age with 
large, intracranial tluid collections 
such as massive hydrocephalus. 
The 3.5 and 5.0 MHz attachments 
are more useful in larger, older 
babies. 

Sequential scans are made by 
placing the transducer over the an- 
terior fontanel first in a coronal and 
then a sagittal direction. The probe 
is then applied to the right and left 
lateral calvarium parallel to the 
canthomeatal line. It is desirable to 
scan from both lateral positions to 
obtain optimum pictures of both 
hemispheres, since the visualiza- 
tion of the area just beneath the 
transducer is frequently com- 
promised by reverberation artifacts 
(Figure 1). 



A videotape of the intracranial 
ultrasonic anatomy is recorded as 
well as intermittent photographic 
prints. This information can then be 
used for further analysis and as a 
permanent record. The ventricular 
dimensions and brain thickness can 
best be measured (± 1mm) during 
the scanning procedure using elec- 
tronic calipers provided on the 
scanning unit. 

Both the anterior and posterior 
fontanels make convenient win- 
dows through which sound waves 
readily pass, although some pene- 
tration is possible through the skull. 




Figure 1: View througii the lateral skull (s) 
showing the lateral ventricles (L) and reverb- 
eration artifact under the skull nearest the 
probe at the top of the picture. 



642 



Vol. 42. No. 9 



"HiiipiiiiiluiuimnMTiiniH 




Figure 2: Coronal view through the anterior 
fontanel showing enlarged lateral ventricles 
(L) and the outline of the temporal lobes 
(arrow). 




Figure 3a: Posterior fontanel approach show- 
ing enlarged posterior horns (L) and clotted 
blood in the left ventricle (arrow). 



Figure 2 shows a coronal view 
through the anterior fontanel with 
moderate ventricular enlargement. 
The posterior fontanel approach is 
illustrated by Figure 3. which shows 
massive dilatation of the posterior 
horns with a clot in the left lateral 
ventricle, a finding verified by com- 
puterized cranial tomography 
(CCT). 

The brainstem has a characteris- 
tic appearance (Figure 4) but the 
close proximity of the many 
brainstem structures often makes 
interpretation difficult. Unfortu- 
nately, the fourth ventricle is not 
consistently visualized. 

DISCUSSION 

Many premature infants have in- 
traventricular or intracerebral 
hemorrhages, and those who sur- 
vive may develop hydrocephalus.'^ 
Because ventricular enlargement 
may start long before the clinical 
signsof increasing ventricular size.' 
recognition at an early stage is im- 
portant so that therapy can be 
started promptly if possible sequel- 
lae are to be prevented. 

Until recently, early visualization 
of ventricular enlargement was pos- 
sible only in CCT scanning. In con- 
trast to the ionizing radiation used 
by the CCT scanners, there are no 
known biological effects from ul- 
trasound in the intensity range used 
for neonatal cerebral imaging. This 
is especially important in infants 
with a protracted course who may 
require several scans. The ul- 
trasound scan can also be done 
without the risk of anesthesia or 
transporting a critically ill infant 
from the nursery. 

Determination of ventricular size 
is currently the most useful aspect 
of this technique. Skolnick et al"" 
compared ultrasound with CCT in 
neonates, and found less than 1 cm 
difference in the biventricular di- 
mensions in 95'7c of cases. In 859c of 
cases, the difference was less than 
.5 cm. Since the posterior lateral 
ventricles are frequently the first to 
enlarge with hydrocephalus, they 
must be visualized ijf early ven- 
tricular enlargement is not to be 
missed (Figure 5). In addition to the 
ventricular system, a large number 
of other intracranial structures have 




Figure 3b: Lateral view of the patient in 3a 
showing enlarged third ventricle (T). 

been identified."* Unfortunately, 
these other structures are less con- 
sistently identified than the ventri- 
cles. In addition, the ultrasonic ap- 
pearance varies somewhat with the 
gestational age of the neonate. Ul- 
trasonic scanning has been used in 




Figure 4: Lateral approach at the level of the 
midbrain. The characteristic heart-shaped 
echo pattern of the quadrigeminal and am- 
bient cisterns is evident (arrows! and the third 
ventricle (T) and the cerebellum (C) are 
shown. 



September 1981. NCMJ 



643 




Figure 5: Posterior horns containing choroid 
plexus (arrow). 



children uptoagetwo^, but its detail 
and reliability become progres- 
sively less satisfactory with in- 
creasing age. 

Although ultrasonic imaging of 
the brain may be limited to infants, 
it represents a promising new de- 
velopment in neonatal neurology. It 
should be possible to replace some 
CCT procedures with ultrasonic 
scans which would be safer, quicker 
and less costly. However, the pro- 
cedure at this time must still be 
viewed as an adjunct to conven- 
tional CCT scanning, since brain 
anatomy is not fully delineated and 
because some parts of the brain 
are not consistently visualized. 
Nevertheless, once the underlying 
pathological process is established, 
serial ultrasonic scanning should be 
helpful in following treatment. A 
controlled study comparing ul- 
trasound with CCT is being under- 
taken to assess the reliability of this 
new procedure. 



ACKNOWLEDGMENTS 

We thank Dr. James Martin of the 
Department of Medical Sonics, 
Bowman Gray School of Medicine, 
for his helpful suggestions, as well 
as our technicians. Donna Lucas 
and Linda Hileman. We also thank 
Megan Shanahan for assistance 
with manuscript preparation. 

References 

1. Babcock DS. Han BK. LcQuesne GW: B-mode gray 
scale ultrasound of the head in the newborn and young 
infant, AJR l34:4.'i7-458. 1980. 

2. Johnson ML. Mack LA. Rumack CM, et al: B-mode 
echoencephaiography in the normal and high risk infant. 
AJR 133;37.s-3g|. 1979, 

3. Pape KE. Blackwell RJ. Cusick G. et al: Ultrasonic 
detection of brain damage in preterm infants. Lancet 
I:i:6l-I264. 1979, 

4. Morgan CL. Trought WS, Rothman SJ. Jimenex JP: 
Comparison of gray-scale untrasonography and com- 
puted tomography in the evaluation of macrocrania in 
mfants. Radiology 132:119-123. 1979, 

5. Skolnick ML. Rosenbaum AE. Matzuk T. et al: Detec- 
tion of dilated cerebral ventricles in infants: a correla- 
tive study between ultrasound and computed tomog- 
raphy. Radiology 131:447-451. 1979. 

6. Papile L. Burslein J. Burslein R. Koppler H: Incidence 
and evolution of subependymal and intraventricular 
hemorrhage: a study of mfants with birth weights less 
than 1-500 gm. J Pediatr 92:.5:9-534. 1978. 

7 Voipe JJ. Pasternak JF. Allen WC: Ventricular dilata- 
tion preceding rapid head growth following neonatal 
intracranial hemorrhage. Am J Dis Child 131:1212-1215. 
1977. 

8. Kossoff G. Garrett WJ. Radavonovich G: Ultrasonic 
atlas of normal brain of infant. Ultrasound Med Biol 
1:259-266. 1974. 



644 



Vol. 42, No. 9 



I 



The Use of Psychotropics in the 
Prison Setting 



James H. Carter, M.D. 



ABSTRACT It is essential that 
definitive guidelines be developed to 
improve upon the effective use of 
psychotropics in prisons. This paper 
presents an overview of some of the 
problems associated with the use of 
psychotropics in prisons while calling 
attention to risks frequently involved 
when psychopharmaceuticals are 
prescribed for inmates. In addition 
to problems with psychotropics, pro- 
viding good health care to prisoners 
has become a controversial subject 
and is of great concern to the medical 
profession. 

I contend that it is imperative to 
examine and establish standards 
for the use of psychotropics in pris- 
ons. The news media, professional 
and non-professional magazines, 
pharmaceutical companies, the 
courts, and the inmates themselves 
are constantly reminding us of the 
problems associated with this issue. 
Over the past decade much progress 
has been made toward the de- 
velopment of standards for health 
care in prisons, with the U.S. De- 
partment of Justice, the American 
Correctional Association, the 
American Public Health Associa- 
tion and the American Medical As- 
sociation being among the most ac- 
tive forces. The North Carolina 



Associate Professor of Psychiatry 

Division of Community/Social Psychiatry 

Duj^e University Medical Center 

Durham. N.C. 27710 

Presented at the American Medical Association's Founh 

National Conference on Medical Care and Health Services 

in Correctional Institutions. Chicago, 111., Oct. 25, 1980. 



Medical Society has vigorously 
pursued methods for improving the 
health care of prisoners, particu- 
larly those in jails, and in 1975 the 
American Medical Association in- 
stituted a program for the accredi- 
tation of medical care in jails. 
Nevertheless, I am in agreement 
with Chalke' who reminds us that 
no nation has reasons to be proud of 
its history of health care for prison- 
ers. 

In addition to problems with 
psychopharmaceuticals, providing 
good health care to prisoners is 
today a very controversial subject 
and is of great concern to the medi- 
cal profession. Regrettably, the 
care rendered prisoners is often 
imbued with fears of legal conse- 
quences. Thus, it comes as no sur- 
prise to learn that correctional 
health facilities which badly need 
medical services are stigmatized 
and ignored by many highly skilled 
health professionals. Litigation in- 
volving the use of psychotropics in 
prisons and mental institutions 
across the country has been in- 
creasing for several years. Regard- 
less of the final disposition made by 
the courts in such cases, the legal 
process is laborious, frustrating and 
potentially damaging to the medical 
staff involved. A staff against whom 
charges have been directed may 
be ruined, both financially and 
psychologically. Therefore, I vehe- 
mently disagree with those who 
are in favor of far reaching legal ac- 
tion to insure adequate health care 



in prisons.- Too often court action 
has resulted in the impingement of 
professional discretion in patient 
care. Instead, I support peer review 
with licensure and accreditation by 
the various standard professional 
bodies as an alternative to a judicial 
process that frightens, alienates and 
deters well-trained and dedicated 
health professionals from entering 
an area where they are desperately 
needed. Treatment in the future — 
whether with psychotropics or 
psychological, individual or group 
methods — must enlist the special 
orientations and skills of everyone 
concerned with health care. 

The fact remains that few physi- 
cians can be expected to derive per- 
sonal and professional satisfaction 
from a practice that discourages the 
full exercise of professional judg- 
ment. Physicians accused of disre- 
garding the civil liberties of inmates 
may now face the dilemma of offer- 
ing timely and appropriate treat- 
ment to severely disturbed indi- 
viduals pending court approval. In a 
recent report on treatment in cor- 
rectional facilities. Newsweek^ 
stated that in some areas of the 
country disturbed prisoners in need 
of psychotropics are being confined 
to isolated cells as an alternative to 
treatment. Emotionally disturbed 
prisoners are said to be kept naked 
to prevent them from harming 
themselves. They are "left without 
medication because it is illegal to 
administer even a mild sedative 
without an inmate's consent. 



September 1981, NCMJ 



645 



Sometimes they just stand and 
scream until space can be found in a 
state hospital." I believe that the 
public will eventually permit the 
judicial pendulum to swing in the 
direction that gives weight not only 
to the wishes of the patient but to 
exigencies of emergency medical 
situations. At the very least, recent 
Supreme Court decisions (Parham 
V. J.L.. 47 U.S.L.W. 4740. 1979. 
and Vietek v. Jones, No. 78-1155. 
Sup. Cf. March 25, 1980), indicate 
that the courts refuse to accept the 
view that medical personnel work- 
ing within corrections will inherent- 
ly compromise their decision mak- 
ing roles and lose their objectivity.^ 
Today we are told that the preva- 
lence of psychoses in prisons may 
range as high as three percent with 
the majority in need of treatment."' 
Simultaneously we must decide 
how practical it is to afford each 
acutely disturbed patient an adver- 
sarial hearing before treatment can 
commence. This dilemma is not 
unique to prisons but is shared by 
many institutions that must care for 
individuals who because of mental 
illness have lost the capacity to 
make rational choices regarding 
their treatment." No informed and 
caring clinician would seek to deny 
any citizen full protection of the 
Constitution and Bill of Rights, 
especially in view of recent court 
decisions.'"" I am convinced that 
the principle of informed consent 
must become a reality and extend 
beyond merely obtaining a patient's 
signature to documents designed to 
indicate an agreement to treatment 
but frequently filled with technical 
jargon. Besides meeting the re- 
quirements of the law, what a 
physician tells a patient regarding 
treatment must reflect the physi- 
cian's perceptions of the illness and 
the patient's mental or emotional 
state at that time. Nevertheless, 
some feel that to insure informed 
consent, patients should be pro- 
vided with professional literature 
about psychotropics including 
copies of the Physician's Desk Ref- 
erence, which was prepared to aid 
clinicians, pharmacists and other 
allied health professionals.'- It is 
doubtful that the lay public can be 
significantly helped by this mate- 

646 



rial; it could increase unwarranted 
fears and anxieties. If material 
about psychotropics is to be given 
to patients, it should be especially 
prepared to accomplish greater en- 
lightment, since the illusion of being 
informed is serious and can contrib- 
ute to an erosion of the physician- 
patient treatment alliance. 

There are many circumstances in 
prisons where the use of psycho- 
tropics is appropriate. Psychotrop- 
ics, ranging from minor tranquiliz- 
ers such as benzodiazepines to ex- 
tremely potent neuroleptics, i.e., 
phenothiazines, can be safely pre- 
scribed by all physicians properly 
trained and thoroughly familiar with 
the actions of these pharmaceuti- 
cals. In essence, the prerequisite is 
that the physicians know three 
things: I) the psychopharmacology 
of the prescribed medication, 2) the 
presenting symptoms of the patient 
and the clinical indications for 
treatment, 3) the stress level in the 
prison environment. 

Familiarity with the 

Psychopliarniacology of 

Psychotropics 

In institutions where there is a 
shortage of professional staff, the 
use of certain psychotropics can 
have serious consequences. For ex- 
ample, the allergic reactions, the 
hypotensive effects and the acute 
dystonic reactions associated with 
neuroleptics can be frightening and 
serious. '■' Tardive dyskinesia which 
can also occur with these particular 
psychotropics may be irreversible 
and invite lawsuits. Because 
neuroleptics are powerful tran- 
quilizers, they may be inappro- 
priately prescribed to curb aggres- 
sive and/or assaultive behavior in 
prisoners who are not psychotic. 
The use of tranquilizers and espe- 
cially neuroleptics with noisy or 
belligerent inmates to facilitate their 
"management" by custodial staff 
should be forbidden. Even with 
cases of acute psychosis long-acting 
neuroleptics should be used cau- 
tiously, particularly when follow-up 
is difficult or impossible. Likewise, 
the appropriate use of lithium car- 
bonate for the treatment of affective 
disorders requires an initial physical 
assessment with periodic monitor-. 



ing of serum lithium levels. Should 
these stipulations with the use of 
lithium become impossible, then the 
choice becomes a neuroleptic. In 
fact, neuroleptics may be selected 
for control of the acute symptoms of 
manic-depressive symptomatology. 
Although psychotropics may be 
more expensive when prescribed as 
concentrates or liquids, this form 
may save lives. Liquids are more 
difficult to hoard and easier to ad- 
minister. Observing inmates as they 
take their medications and dis- 
couraging their discretionary use of 
tablets instead of liquids can help 
immensely. The potential for the 
misuse of psychotropics is so great 
in prisons as to dictate that inmates 
not assist with preparing or dis- 
pensing medications. Due to physi- 
cal discomfort, the use of even 
high-potency low-dose intramus- 
cular medicines should be kept to a 
minimum. 

In spite of precautions, there are 
rare instances in prisons where 
physical and/or emotional depen- 
dence upon a particular psycho- 
tropic may be unavoidable. In cases 
of certain malignancies or terminal 
diseases, the most judicious use of 
some psychotropics may result in 
tolerance and ultimately depen- 
dence.'^ Underthese conditions the 
physician must be guided by his best 
clinical judgment and/or consulta- 
tion with peers. Ordinarily, medi- 
cines are prescribed to restore peo- 
ple to a state of health, or to prevent 
certain illnesses from occurring. 
Physicians have tried to relieve the 
emotional pain of prisoners with 
drugs that could not heal or cure.'^ 
Antiparkinson agents, widely 
prescribed to curb the side effects of 
neuroleptics, are frequently abused 
by prisoners because of their an- 
ticholinergic properties. It is in- 
teresting to note that clinicians are 
now weighing the value of antipar- 
kinson drugs in preventing ex- 
trapyramidal symptoms against 
concerns that these medications 
may interfere with neuroleptic ab- 
sorption. In fact, some clinicians 
suggest that these preparations may 
exacerbate tardive dyskinesia or in- 
duce toxic brain syndrome. It is 
concluded that the use of p.r.n. or- 
ders is to be discouraged and we 



Vol. 42. No. 9 



i 






should individualize the use of 
psychotropics for a specific set of 
symptoms. 

Awareness of the Presenting 
Symptoms 

A knowledge of psychophar- 
macology and the clinical indica- 
tions for treatment are inseparable. 
However, incarceration by its 
stressful nature evokes enormous 
emotional turmoil which can give 
rise to a variety of physical and 
emotional symptoms. Most com- 
monly recognized are depressions 
and/or states of anxiety that could 
probably be treated with psycho- 
tropics with few if any risks under 
different clinical circumstances. 
Parenthetically, a significant num- 
ber of situational conditions exist 
among prisoners which are found to 
be transient and respond favorably 
to non-psychotropic forms of 
treatment. Therefore, the risks I see 
with psychotropics in prison set- 
tings are: 1) creating and/or con- 
tinuing a psychological and/or a 
physiological dependence on 
psychotropics, 2) creating for in- 
mates a situation in which they face 
psychological intimidation and/or 
physical threats from other inmates 
who may wish to obtain these medi- 
cations for themselves or for bar- 
tering, 3) prescribing medications 
that would add to the pool of con- 



traband drugs already present, thus 
increasing the probability of over- 
dosages and suicides. Suffice it to 
say, appropriate use of psycho- 
tropics with mentally retarded and 
psychotic inmates is essentially the 
same as with non-prisoners in pub- 
lic or private institutions. With this 
category of relatively dependent, 
defenseless inmates, it is apparent 
that all the risks previously men- 
tioned become extremely important 
in prisons. 

The Prison Environment 

The milieu of a prison is unique, 
composed of an involuntarily con- 
fined population. It is an environ- 
ment of individuals who have been 
identified and found guilty of trans- 
gressions against the laws of soci- 
ety. Uncommon effects of sensory 
deprivation may be encountered, 
resulting from enforced isolation or 
a natural consequence of the envi- 
ronment, and failure to recognize 
such symptoms may result in the 
inappropriate prescription of 
psychotropics. Finally, boredom 
from the prison milieu may give rise 
to the wish to escape reality, and 
there are inmates who will attempt 
to do this with the sustained use of 
psychotropics, regardless of the 
consequences. 

Finally, it is impossible to discuss 
inthisbriefpaperallofthe problems 



related to the use of psychotropics 
in prisons. However, through con- 
tinued education, consultation and 
training, the improved use of 
psychotropics with prisoners can be 
made possible. The abatement of 
pain, physical or emotional, has 
been considered a desirable goal 
since the beginning of medicine. 
Thus, preventing and treating 
physical or emotional symptoms are 
the major reasons why medicines 
are prescribed, regardless of the 
setting. 

References 

1. Chaike F: Prison psychiatry: a survey of ethical guide- 
lines, Psychiatr Ann 8:63-77, 1978. 

2. Kaufman E: The violation of psychiatric standards of 
care in prisons. Am J Psychiatry 137:566-570. 1980. 

3. Newsweek. The scandalous U.S. jails. August 18. 
74-77. 1980. 

4. Transfer from a prison to a mental hospital. Mental 
Disability Law Reporter. ABA Mental Disability Legal 
Resource Center. 1800 M Street. Washington. D.C.. 
4:146-147. 1980. 

5. James FJ. Gregory D. Jones RK: Psychiatric morbidity 
in prisons. Hosp Community Psychiatry 31:674-755. 
1980. 

6. Appelbaum PS. Gulheil TO: Drug refusal: "a study of 
psychiatric inpatients. '* Am J Psychiatry 137:340-344. 
1980. 

7. Smith CH: Confidentiality-privacy — right to treatment 
— right to refuse. Mental health for the convicted of- 
fender patient and prisoner tmonograph). North Caro- 
lina Department ofCorrections. Raleigh. N.C 127-128, 
1977, 

8. Rennie v. Klein, 462 F. Supp. 1 131 (D.N.J. 19781. 

9. Parham v. JR.. 99 S Of. 2493 (1979). 

10. Wyatt V. Strickney, 325 F. Supp. 781, 785 (N.D. Ala. 
1971). 

11. .^ddington v. Texas, 47 U.S.L.W. 4473 (1979). 

12. Physician's Desk Reference, Charles Baker Publisher, 
Medical Economics Company. Oradell, N.J., 1979. 

13. Baldessarini RJ: The "neuroleptic" antipsychotic 
drugs. Postgrad Med 65:108-128. 1979. 

14. Carter JH: The alcoholic and the drug abuser. Mental 
Health for the convicted offender patient and prisoner 
(monograph). North Carolina Department of Correc- 
tions. Rale'gh, N.C. 101-103. 1977. 

15. Cohen S: Drugs for pleasure: ethical issues. Drug Abuse 
and Alcoholism Newsletter. Vistal Hill Foundation, 
San Diego. Calif. Vol. 8. September 1979. 



,,;! September 1981, NCMJ 



647 



Toxic Encounters of the Dangerous Kind— 



ANTIHISTAMINE TOXICITY 



These drugs are among the most com- 
mon medications found in the homes of 
our patients. Both OTC and prescription 
varieties are numerous, primarily as 
"cold" medicines, allergy remedies and 
non-prescription "sleeping pills" (e.g., 
Sominex, Unisom, Miles Nervine). 

Most practitioners are aware that an 
overdose of antihistamines in an adult 
causes CNS depression marked by 
drowsiness, inability to concentrate, dis- 
turbed coordination and blurred vision. 
These features are common in people 
even on therapeutic doses. In marked 
overdose, coma can occur. But are you 
aware that in children an overdose of an 
antihistaminic can cause CNS excitation? 

Children are particularly susceptible to 
the CNS stimulatory effects of the an- 
tihistamines with such clinical features as 
tremors, hyperactivity, hyper-reflexia, 
hallucinations (very common in our ex- 
perience), ataxia, athetosis, insomnia and 
tonic-clonic convulsions being observed. 
Antihistamines have anticholinergic ef- 
fects which may be the cause of these 
clinical manifestations, as well as of 
flushed skin, fever, tachycardia and my- 
driosis. Children seem to be especially 
sensitive to these anticholinergic effects. 

Most of the fatalities from antihis- 
tamine toxicity have been in children. 
Children who die from an overdose have 



uncontrolled seizures progressing to 
coma and cardiorespiratory arrest. The 
lethal dose in man is not known for most 
antihistamines but 25-50 mg/kg (20 to 30 
tablets) can represent a fatal dose for a 
child. These drugs are rapidly absorbed 
from the GI tract with adverse symptoms 
developing within 1-2 hours (except with 
the time released preparations). 

Treatment consists of gastric emptying 
via ipecac or lavage followed by activated 
charcoal and a saline cathartic (with time 
release preparations late gastric emptying 
is probably indicated). There is no 
specific antidote but control of seizures 
should be attempted with diazepam or 
short acting barbiturates (adverse syner- 
gistic sedative effect is a danger here) and 
the severe anticholinergic effects can be 
treated cautiously with physostigmine. 
Forced diuresis or dialysis is not helpful. 

The next time you see a preschool child 
who is hallucinating and very agitated, 
think of antihistamine overdose. 

Ronald B. Mack, M.D. 

Department of Pediatrics 

Bowman Gray School of Medicine 
of Wake Forest University 

Winston-Salem, N.C., and 

Chairman, Committee on Accidents 
and Poison Prevention 

North Carolina Chapter of the 
American Academy of Pediatrics 



648 



Vol. 42. No. 9 



J 





■VS -• 



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For th^WS^QpKDsteoarthritis 
the proven power of « 

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Please see the following page for a brief summary of prescribing information. 



l^john 



b Upjohn Company 



The Upjohn Company • Kalamazoo, Michigan 49001 USA 



Motrin" Tablets (ibuprofen, Upjohn) 

Contraindications: Individuals hypersensitive to it, or vi/ith ttie syndrome of nasal 
polyps, angioedema, and bronchospastic reactivity to aspirin, iodides, or ottier non- 
steroidal anti-inflammatory agents, Anaptiylactoid reactions have occurred in such 
patients. 

Warnings: Peptic ulceration and gastrointestinal bleeding, sometimes severe, have 
been reported. Ulceration, perforation, and bleeding may end fatally An association has 
not been established. Motrin should be given under close supervision to patients with a 
history of upper gastrointestinal tract disease, only after consulting ADVERSE REAC- 
TIONS 

In patients with active peptic ulcer and active rheumatoid arthritis, nonulcerogenic 
drugs, such as gold, should be tried If Motrin must be given, the patient should be under 
close supervision for signs of ulcer perforation or gastrointestinal bleeding 

Chronic studies in rats and monkeys have shown mild renal toxicity characterized by 
papillary edema and necrosis. Renal papillary necrosis has rarely been shown in 
humans treated with Motrin. 

Precautions: Blurred and/or diminished vision, scotomata. and/or changes in color 
vision have been reported. If these develop, discontinue Motrin and the patient should 
have an ophthalmologic examination, including central visual fields and color vision 
testing. Fluid retention and edema have been associated with Motrin; use with caution in 
patients with a history of cardiac decompensation or hypertension. Motrin is excreted 
mainly by the kidneys. In patients with renal impairment, reduced dosage may be nec- 
essary Prospective studies of /Mofr/n. safety in patients with chronic renal failure have 
not been done. Motrin can inhibit platelet aggregation and prolong bleeding time. Use 
with caution in persons with intrinsic coagulation defects and those on anticoagulant 
therapy. Patients should report signs or symptoms of gaslroinleslinal ulceration or 
bleeding, blurred vision or other eye symptoms, skin rash, weight gain, or edema To 
avoid exacerbation of disease or adrenal insufficiency, patients on prolonged cortico- 
steroid therapy should have therapy tapered slowly when Motrin is added. The anti- 
pyretic, anti-inflammatory activity of Motrin may mask inflammation and fever 
Drug interactions. Aspirin: used concomitantly may decrease Motrin blood levels. 
Coumarin: bleeding has been reported in patients taking Motrin and coumarin 
Pregnancy and nursing mothers: Motrin should not be taken during pregnancy nor by 
nursing mothers. 
Adverse Reactions 

The most frequent type of adverse reaction occurring with Motrin is gastrointestinal, of 
which one or more occurred in 4% to 16°o of the patients 

Incidence Greater Than 1% (but less than 3%) -Probable Causal Relationship 
Gastrointestinal: fJauseaf' epigastric pain: heartburn: diarrhea, abdominal distress, 
nausea and vomiting, indigestion, constipation, abdominal cramps or pain, fullness of Gl 
tract (bloating and flatulence); Central Nervous System: Dizziness; headache, nervous- 
ness; Dermalologic: Rash - (including maculopapular type), pruritus; Special Senses: Tin- 
nitus; Metabolic/Endocrine: Decreased appetite; Cardiovascular: Edema, fluid retention 
(generally responds promptly to drug discontinuation; see PRECAUTIONS) 
Incidence Less Than 1% -Probable Causal Relationship " 

Gastrointestinal: Gastric or duodenal ulcer with bleeding and/or perforation, gastroin- 
testinal hemorrhage, melena, gastritis, hepatitis, jaundice, abnormal liver function tests; 
Central Nervous System: Depression, insomnia, confusion, emotional lability, somnolence, 
aseptic meningitis with fever and coma; Dermalologic: Vesiculobullous eruptions, urti- 
caria, erythema multiforme, Stevens-Johnson syndrome, alopecia. Special Senses: 
Hearing loss, amblyopia (blurred and/or diminished vision, scotomata, and/or changes 
in color vision) (see PRECAUTIONS); Hematologic: Neutropenia, agranulocytosis, aplastic 
anemia, hemolytic anemia (sometimes Coombs' positive), thrombocytopenia with or 
without purpura, eosinophilia, decreases in hemoglobin and hematocrit; Cardiovascular: 
Congestive heart failure in patients with marginal cardiac function, elevated blood 
pressure, palpitations; Allergic: Syndrome of abdominal pain, fever, chills, nausea and 
vomiting, anaphylaxis, bronchospasm (see CONTRAINDICATIONS); Renal: Acute renal 
failure in patients with preexisting, significantly impaired renal function, decreased 
creatinine clearance, polyuria, azotemia, cystitis, hematuria; Miscellaneous: Dry eyes 
and mouth, gingival ulcer, rhinitis. 
Incidence Less Than 1%-Causal Relationship Unknown" 
Gastrointestinal: Pancreatitis; Central Nervous System: Paresthesias, hallucinations, 
dream abnormalities, pseudotumor cerebri; Dermalologic: Toxic epidermal necrolysis, 
photoallergic skin reactions; Special Senses: Coniunctivitis, diplopia, optic neuritis; 
Hematologic: Bleeding episodes (e.g., epistaxis, monorrhagia); Metabolic/ Endocrine: Gyne- 
comastia, hypoglycemic reaction; Cardiovascular: Arrhythmia (sinus tachycardia, sinus 
bradycardia); Allergic: Serum sickness, lupus erythematosus syndrome, Henoch- 
Schonlein vasculitis; Renal: Renal papillary necrosis. 

'■'Reactions occurring in 3% to 9% of patients treated with Motrin. (Those reactions 
occurring in less than 3°o of the patients are unmarked.) 

"Reactions are classified under "Probable Causal Relationship" (PCR) if there has been 
one positive rechallenge or if three or more cases occur which might be causally related. 
Reactions are classified under "Causal Relationship Unltnown" if seven or more events 
have been reported but the criteria for PCR have not been met 
Overdosage: In cases of acute overdosage, the stomach should be emptied The drug 
IS acidic and excreted in the urine, so alkaline diuresis may be beneficial. 
Dosage and Administration: Do not exceed 2400 mg per day. If gastrointestinal 
complaints occur, administer with meals or milk. 

Rheumatoid arthritis and osteoarthritis, including flares of chronic disease; Sug- 
gested dosage is 300, 400, or 600 mg t,i.d. or q.i.d. Mild to moderate pain: 400 mg every 
4 to 6 hours as necessary for relief of pain 

Caution: Federal law prohibits dispensing without prescription. 

MEDB-5-S 



Ultibhn 



THE UPJOHN COMPANY 
Kalamazoo. Michigan 49001 USA 



5pec/fy 

LibrBH 




Each capsule contains 5 mg chlordiazepoxide HCI and 2.5 mg 
clidinium Br. 

Please consult complete prescribing information, a summary of 
which follows: 



indications: Based on a reuiew of ttiis drug by trie national 
Academy of Sciences — national Research! Council and/or other 
information, FDA has classified the indications as follows 
"Possibly" effective as adjunctive therapy in the treatment of 
peptic ulcer and in the treatment of the irritable bowel 
syndrome (irritable colon, spastic colon, mucous colitis) and 
acute enterocolitis. 

Final classification of the less-than-effective indications re- 
quires further investigation 



Contraindications: Glaucoma, prostatic hypertrophy, benign 
bladder neck obstruction, hypersensitivity to chlordiazepoxide 
MCI and/or clidinium bromide 

Warnings: Caution patients about possible combined effects with 
alcohol and other Cn5 depressants, and against hazardous occupa- 
tions requiring complete mental alertness (eg, operating 
machinery, driving) Physical and psychological dependence rarely 
reported on recommended doses, but use caution in administering 
Librium" (chlordiazepoxide MCl/Fioche) to known addiction-prone 
individuals or those who might increase dosage, withdrawal symp- 
toms (including convulsions) reported following discontinuation of 
the drug 

Usage in Pregnancy: Use of minor tranquilizers during first 
trimester should almost always be avoided because of 
Increased risk of congenital malformations as suggested in 
several studies. Consider possibility of pregnancy when 
instituting therapy. Advise patients to discuss therapy if 
they intend to or do become pregnant. 
As With ail anticholinergics, inhibition of lactation may occur 
Precautions: In elderly and debilitated, limit dosage to smallest 
effective amount to preclude ataxia, oversedation, confusion (no 
more than 2 capsules'day initially, increase gradually as needed and 
tolerated) Though generally not recommended, if combination 
therapy with other psychotropics seems indicated, carefully consider; 
pharmacology of agents, particularly potentiating drugs such as MAO: 
inhibitors, phenothiazines Observe usual precautions m presence ofi 
impaired renal or hepahc function Paradoxical reactions reported in ' 
psychiatric patients Employ usual precautions in treating anxiety 
states with evidence of impending depression, suicidal tendencies 
may be present and protective measures necessary Variable effeci 
on blood coagulation reported very rarely in patients receiving the 
drug and oral anticoagulants, causal relationship not established 
Adverse Reactions: flo side effects or manifestations not seen with 
either compound alone reported with Librax When chlordiazepoxide; 
nCI IS used alone, drowsiness, ataxia, confusion may occur, es- 
pecially in elderly and debilitated, avoidable in most cases by propel 
dosage adjustment, but also occasionally observed at lower dosage 
ranges Syncope reported in a few instances Also encountered 
isolated instances of skin eruptions, edema, minor menstrual 
irregularities, nausea and constipation, extrapyramidal symptoms, 
increased and decreased libido — all infrequent, generally controlled 
with dosage reduction, changes in EEQ patterns may appear during 
and after treatment, blood dyscrasias (including agranulocytosis). 
Jaundice, hepatic dysfunction reported occasionally with chlor- 
diazepoxide MCI, making periodic blood counts and liver function 
tests advisable during protracted therapy. Adverse effects reported 
with Librax typical of anticholinergic agents, i e , dryness of mouth, 
blurnng of vision, urinary hesitancy, constipation Constipation has 
occurred most often when Librax therapy is combined with other 
spasmolytics and/or low residue diets 



July 1981 




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Manati, Puerto Rico 00701 



I 



ROCHE 



4 



ORDERS 



of Irritable Bowel Syndrome* 
and Peptic Ulcer* 

Llbrax...the only Q.l. medication that 
provides the action of LIbrlunn® 
(chlordlazepoKlde MCI) to relieve the 
accompanying anxiety found In some 
patients, plus the action of Quarzan® 
(didlnlum bromide) to reduce colonic 
spasm and gastric hypersecretion. 



5pedfy 
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Each capsule contains 5 nng chlordiazepoxide HCI 
and 2.5 mg clidinium Br. 

Miianxiety/^tisecretory/ 
/^ti5pa5nnodic 



♦LIbrax has been evaluated as possibly effective 
for these Indications. Pleas^ see summary of 
prescribing Information on facing page. 



In Hypertension... When You Need to Conserve K 

Every 
Step ^f 

of the 
Way 




Each capsule 

contains 50 mg, of 

Dyrenium' (brand of triamterene) 

and 25 mg. of fiydrocfilorotfniazide 



itep 1 usually consists of an initial phase (a diuretic 
alone), a titration phase [dosage adjustment and/or 
addition of a K+ supplement or K+-sparing agent), ani 
maintenance phase (a diuretic alone or in combinatic 
with a K+ supplement or K+-sparing agent). 



Serum K+ and BUN should be checked periodically (see Warnings). 



Before prescribing, see complete prescribing intormation 
in SK&F Co. literature or PDR. Ttie following is a brief 
summary. 



WARNING 

This drug is not indicated for initial therapy o( edema or 
hypertension Edema or hypertension requires therapy 
titrated to the individual If this combination represents 
the dosage so determined, its use may be more con- 
venient in patient management Treatment of hyperten- 
sion and edema is not static, but must be reevaluated 
as conditions in each patien! warrant. 



Contraindications: Further use in anuria, progressive renal 
or hepatic dysfunction, hyperkalemia. Pre-existing elevated 
serum potassium Hypersensitivity to either component or 
other sulfonamide-derived drugs. 

Warnings: Do not use potassium supplements, dietary or 
otherwise, unless hypokalemia develops or dietary intake 
of potassium is markedly impaired. It supplementary potas- 
sium IS needed, potassium tablets should not be used Hyper- 
kalemia can occur, and has been associated with cardiac 
irregulahties. tt is more likely in the severely ill. with unne 
volume less than one liter/day the elderly and diabetics with 
suspected or confirmed renal insufficiency Periodically 
serum K-*- levels should be determined. If hyperkalemia 
develops, substitute a thiazide alone, restrict K+ intake Asso- 
ciated widened QRS complex or arrhythmia requires 
prompt additional therapy. Thiazides cross the placental 
barrier and appear in cord blood. Use in pregnancy 
requires weighing anticipated benefits against possible haz- 
ards, including letal or neonatal jaundice, thrombocytopenia, 
other adverse reactions seen in adults Thiazides appear and 



triamterene may appear m breast milk If their use is essential, 
the patient should stop nursing Adequate information on use 
in children is not available Sensitivity reactions may occur 
in patients with or without a history of allergy or bronchial 
asthma Possible exacerbation or activation of systemic lupus 
erythematosus has been reported with thiazide diuretics 
Precautions: Do periodic serum electrolyte determinations 
[particularly important in patients vomiting excessively or 
receiving parenteral fluids) Periodic BUN and serum cre- 
atinine determinations should be made, especially in the 
efderly diabetics or those with suspected or confirmed renal 
insufficiency Watch for signs of impending coma in severe 
liver disease. If spironolactone is used concomitantly deter- 
mine serum K+ frequently, both can cause K+ retention and 
elevated serum K+ Two deaths have been reported with 
such concomitant therapy [m one, recommended dosage 
was exceeded, m the other, serum electrolytes were not 
properly monitored) Observe regularly lor possible blood 
dyscrasias, liver damage, other idiosyncratic reactions Blood 
dyscrasias have been reported in patients receiving tri- 
amterene, and leukopenia, thrombocytopenia, agranulocy- 
tosis and aplastic anemia have been reported with thiazides 
Triamterene is a weak folic acid antagonist. Do penodic 
blood studies m cirrhotics with splenomegaly Antihyperten- 
sive effects may be enhanced m post-sympathectomy 
patients. Use cautiously in surgical patients. The following 
may occur transient elevated BUN or creatinine or both, 
hyperglycemia and glycosuria (diabetic insulin requirements 
may be altered), hyperuricemia and gout, digitalis intoxica- 
tion (m hypokalemia), decreasing alkali reserve with pos- 
sible metabolic acidosis Dyazide' interferes with fluorescent 
measurement of quinidine. Hypokalemia is uncommon with 
Dyazide', but should it develop, corrective measures should 
be taken such as potassium supplementation or increased 



dietary intake of potassium-nch foods Corrective measL 
should be instituted cautiously and serum potassium le' 
determined Discontinue corrective measures and Dyaz 
should laboratory values reveal elevated serum potassii 
Chloride deficit may occur as well as dilutional hyponatrer 
Serum PBI levels may decrease without signs of thyi 
disturbance Calcium excretion is decreased by ihiazk 
Dyazide' should be withdrawn before conducting tests 
parathyroid function. 

Diuretics reduce renal clearance of lithium and increase) 
risk of lithium toxicity. 
Adverse Reactions: Ivluscle cramps, weakness, dizzini; 
headache, dry mouth, anaphylaxis, rash, urticaria, pfii 
sensitivity, purpura, other dermatological conditions, nau 
and vomiting, diarrhea, constipation, other gastroinlest 
disturbances. Necrotizing vasculitis, paresthesias, icte 
pancreatitis, xanthopsia and, rarely allergic pneumot 
have occurred with thiazides alone Triamterene has t) 
found in renal stones m association with other usual calci 
components Rare incidents of acute interstitial nephritis; 
of impotence have been reported with the use of 'Dyazi, 
although a causal relationship has not been established, 
Supplied: Bottles of 1000 capsules; Single Unit Packa' 
(unit-dose) of 100 (intended for institutional use only] 
Patient-Pak'"^ unit-of-use bottles of 100. 



SI^&F CC 

a SmithKlme compai 

Carolina. PR 00630 



ply 



ffes 



Still 



«>SK&FCo.. 1980 




MEDICINE AND THE MEDIA 

One of the canons of experts in communications 
today is that great things can be expected by getting to 
know your media man better. Presumably your own 
story will be told better, the media will acquit its 
responsibility more nobly and the world will be a 
better place thereby. To get to know one's media man 
and woman better, one can invite him or her to lunch. 
Because media are as numerous as muses, this may 
mean a big lunch, the cost of which can be charged off, 
if your organization is a legitimate business, or rep- 
resented as a proper expense for altruistic societies. 

So our county medical society recently had a media 
luncheon. Town and gown. TV and radio, newspaper 
and medicine man and woman were all represented. 
Some of us knew each other and chatted, others 
sought hasty introductions and shook hands gingerly 
before sitting down to eat at the standard U-shaped 
table. The media folk sat down to the right of our 
officers, the medical contingent down to the left and 
attacked a reasonably good meal, an essential to all 
such gatherings. 

Halfway through the dessert the discussion began 
as we sought to learn more about each other's busi- 
ness. It soon became apparent that some of our guests 
thought they had been invited to be cultivated, even to 
be encouraged to manage news and suspected that we 
physicians might be a bit doctrinaire. But as conver- 
sation continued, several important points emerged. 

1 . Physicians may have a distorted view of news 
gathering in the modern world. TV, for example, has 
little time to develop stories and provide even minimal 
continuity. It offers a transient limelight, uncomfort- 
able for the physician concerned with pathogenesis, 
prognosis and the ultimate place in medicine of the 
latest from the laboratory. 

2. Look for medical continuity in medical journals 
and monographs and in magazines. The daily press, 
radio and TV simply cannot provide it. The best medi- 
cal writing in this country is not being done by physi- 
cians either. Read the Annals of Medicine in the New 
Yorker to see how Berton Roueche does it. 

3. The half-life of news is short. Better a good story 
quickly than sustained bureaucratic dullness. 

4. The public needs medical information and we as 
physicians have an obligation to provide it. There may 
be more danger in anonymity than in an occasional 
incorrect attribution. 

5. To doctors, articles about medicine will always 
present the story from the outside. How can it be 



otherwise, given the backgrounds of writers and audi- 
ences? Local physicians, however, do need to be 
available to reporters who have not had medical 
training and who don't necessarily share vocabularies 
with us. Reporters are not trying to embarrass physi- 
cians. 

6. Don't parrot a party line. Newsmen must be 
suspicious and skeptical, just as most physicians. We 
take different types of histories but we are both con- 
cerned with Who? What? When? Where? Which? 
What kind of? How many? 

7. Neither physicians nor the media can always be 
relied on to tell the difference between news, publicity 
and propaganda despite our protestations to the con- 
trary. We deceive ourselves easier than we do each 
other and must always be ready to correct our own 
mistakes and misapprehensions. 

8. Trust will sometimes be betrayed through igno- 
rance or misunderstanding, rarely intentionally. 

9. The next time you have media luncheon, use 
place cards. 

J.H.F. 



BOOK REVIEW 

The Story of an Idea — E. Metchnikoff s Work 
by A. Besredka. Bend, Oregon: Maverick Publi- 
cations, 1979, 86 pp. 

This is a translation by A. Rivenson, M.D., and 
R. Oestreicher, M.D., of Besredka's 1921 monograph, 
part of a Pasteur Institute series, published in Paris by 
Masson. Besredka was a Pasteur Institute professor 
who had spent 20 years in the company of Metch- 
nikoff, for whom he had immense respect. In this short 
work he discusses the 1908 Nobel prize winner's work 
(with Paul Ehrlich) under the headings of em- 
bryogenesis. inflammation, immunity, aging, pathol- 
ogy and philosophy. There is a brief foreword by 
Rivenson. one of the translators, and a preface by the 
late Dr. Ludwik Gross, who worked with Besredka for 
eight years before coming to this country, where he 
did outstanding work with transmissible leukemias of 
animals. 

Now that Metchnikoff has achieved his place 
among the immortals it is difficult to appreciate his 
struggles to gain acceptance for his observations on 
immunity. As the person who brought the macrophage 
into prominence and who would be delighted to see 
what his early work has led to, he had to contend with 



September 1981, NCMJ 



653 



the early authorities in immunology whose whole cast 
of mind was toward the humoral aspects of immunity. 
It is part of Metchnikoff s achievement that he was by 
nature a fighter, quite confident in the truth of his 
observations without being overextended in his in- 
terpretations. Besredka shared his confidences and 
provides an insight into the man's attitudes that is hard 
to come by elsewhere. 

The book — more a pamphlet — is fascinating, 
charming and stimulating. Following the unfolding of 
the insights of genius is always awesome; things are 
made to look so simple and obvious even though the 
reader knows of all the work and transcendental rea- 
soning that had to take place before the truth emerged. 
Metchnikoffs concern with aging and diet — he is 
more responsible for the popularity of yogurt than 



most people realize — are not dealt with at length, 
perhaps indicating that Besredka, in 1921, did not 
realize how great an interest the public had in this part 
of his mentor's activity. 

The charm of the book comes not only from what 
Besredka had to say, but with the translation, which 
can best be described as accented, something said 
without derogation. Had it been edited to remove 
improperly-chosen idioms and certain misspellings a 
lot would have been lost. Dr. Rivenson advises that 
there are only 10 copies of the original French work 
and 500 of the English translation. Anyone with an 
interest in the history of immunology, or in the field of 
comparative biology or medicine, will find this a gem 
for his collection. 

R.W.P. 



MEDICAL PLACE AT 

JLCAPE 
■irCENTER 




Here is an opportunity for you in one of 
the more progressive regional medical 
communities "Fayetteville, North Caro- 
lina". 

Adjacent to the Cape Fear Valley Hospi- 
tal, Vyquest Development Corp. is de- 
veloping an outstanding condominium 
building satisfying the needs of the 
growth oriented medical professional. 
Not only do we have a handsome, effi- 
cient building, but we have it in the 
superbly planned Cape Center Office 
Park in the region's most desirable and 
sought after location. 

For our brochure, call 919-484-6530 or 
send your card to: 

Vyquest Development Corp. 

3300 Cape Center 

Fayetteville, North Carolina 28304 



654 



Vol. 42, No. 9 





04- 

TARTNfR 



By Lynn Olson Dowling 

Assistant Director 

Department of Practice Management 

Division of Medical Practice 

American Medical Association 

When we asked several physicians using office- 
based patient education programs if they'd been 
successful, the unanimous reply was, "Definitely!" 
And, most added that they would encourage their 
colleagues to do the same. 

Systems can range from simple brochures to 
video-cassettes to professionals trained in health 
education. Physicians responding to an informal 
questionnaire shared their experiences in using 
various forms of patient education. Saved time and 
increased patient compliance with treatment reg- 
imens were cited as two big pluses of patient edu- 
cation. Some physicians reported that their "in- 
formed" patients provided a better history, sought 
treatment earlier and were less likely to suffer 
reoccurrences of their illnesses. Others added that 
they viewed their patient education program as a 
helpful supplement to informed consent. 

It's important to remember, as one physician 
pointed out, that patient education isn't a substi- 
tute for instruction by you. In his words, "It's a 
supplement which reinforces my personal instruc- 
tion. I find that after viewing our tapes that my 
patients ask more relevant questions." 

Your staff can enjoy benefits as well. "Due to a 
lack of repeat questions, my office personnel are 
freed to handle other tasks," reports one busy 
pediatrician. Informed patients are also less apt to 
be no-shows. Another said, "My glaucoma patients 
now seem to better understand the need for fol- 
low-up." And, patients might even be more con- 
scientious about their bills. One ophthalmologist 
explains: "My patients are getting something 
which other physicians of my specialty don't have 
— they probably realize the cost factor involved, 
hence better collections." All of these benefits add 

September 1981. NCMJ 



up to better office-patient relationships, a fact the 
surveyed physicians attest to strongly. "Better un- 
derstanding leads to better relationships. My 
non-medical personnel are very interested in our 
films." 

There are a wealth of patient education systems 
as well as suppliers for you to choose from. The 
American Medical Association offers an extensive 
number of inexpensive publications; topics range 
from allergies to venereal disease. Write to the De- 
partment of Health Education, AMA, for a free copy 
of their catalog. Many medical specialty societies 
also publish excellent brochures, so be sure to 
check with yours. The American Group Practice 
Association, in conjunction with a patient educa- 
tion consulting firm has developed a comprehen- 
sive patient education program forgroup practices 
and can even provide a consultant to train your 
patient education "staff." Both the American Hos- 
pital Association and HEW's Center for Disease 
Control maintain up-to-date listings of many com- 
mercial suppliers of patient education materials, 
audio-visuals, and films. 

What about costs? Simple brochures will begin 
at about 25 cents a piece, with substantial dis- 
counts given when you order in quantity. The cost 
of film cassettes, movies, and videotapes will vary 
— suppliers suggest that most physicians start 
with an average of eight film cassettes and one 
viewer/projector. The entire package can be leased 
for between $45 and $70 a month. To buy the pack- 
age outright will run somewhere in the neighbor- 
hood of $1,000 to $2,000. If contemplating an 
audio-visual system, be sure to have a commercial 
representative visit your office for a demonstration. 
You'll want to make sure you have adequate space 
available and that the information is in line with 
your treatment philosophy. 

Today's "tuned in" patient wants to know more 
about their condition. Your patient education sys- 
tem could help to meet that need. 



655 



NORTH CAROLINA DIVISION OF HEALTH SERVICES 

Conjoint Report 
To The North Carolina Medical Society 

Ron Levine, M.D., M.P.H. 



I greatly appreciate the opportu- 
nity to once again fulfill this most 
pleasant of statutory obligations — 
to convey to the membership of the 
North Carolina Medical Society at 
our annual meeting a report of ac- 
complishments achieved, of prob- 
lems faced, and of obstacles loom- 
ing ahead that threaten the capacity 
of your state health agency, its staff 
of professional health workers and 
our sister local health departments 
in North Carolina to meet in an ef- 
fective manner the pressing health 
needs of our citizens. 

Being a wholly positive person, 1 
will not dwell upon such formidable 
adversaries as our continuing epi- 
demic of teenage pregnancy — chil- 
dren having children — or such 
vexing yet surely soluble enigmas as 
the carnage upon our highways, nor 
finally such provoking and innately 
unfair facts of North Carolina life 
(or death, as it were) as the still 
gaping abyss between the health in- 
dices recorded by our white citizens 
as contrasted with our black and In- 
dian neighbors. I allude to them 
only to say that we will continue, 
with your very material collabora- 
tion and assistance, to assault these 
patently unacceptable situations in 
our beloved state and hope to 



From the Division of Health Services. 
Department of Human Resources 
State of North CaroHna 
Raleigh, N.C, 27602 

Presented at the annual meeting of the N.C. Medical Soci- 
ety. Pinehurst. N.C, May 8. 1981. 



656 



punctuate future reports with news 
of battles won in these arenas. Let 
me, then, be the bearer of some 
good news from a variety of pro- 
gram areas, with special attention to 
an outstanding area of accomplish- 
ment, immunization, and to another 
area of concentration, environmental 
health services, which we have not 
sufficiently emphasized in recent 
reports to this body. 

The state's fledgling screening 
program for congenital hypothy- 
roidism successfully identified and 
brought to treatment 1 1 youngsters 
with this abnormality in 1980. The 
public-private cooperative system 
that resulted in the salvaging of 
those babies as well three additional 
babies diagnosed as having phenyl- 
ketonuria is something of which we 
can all be proud. 

Local health department nurses 
reviewed 86% of our state's 84,481 
newborn records in an attempt to 
detect babies at greatest risk of en- 
countering developmental prob- 
lems and went to great lengths to 
ensure that every one of those 
high-risk babies was enrolled in a 
regular system of care, either pri- 
vate or public. 

Much-needed health services 
were provided to over 20,000 mi- 
grant agricultural farm workers as 
they streamed through our state last 
spring and summer providing es- 
sential assistance with North Caro- 
lina's bountiful harvest. 

Almost half a million home visits 



were provided by our North Caro- 
lina home health agencies to home- 
bound individuals, enabling them to 
avoid expensive nursing home and 
hospital beds. 

Our Human Tissue Donation 
Program began a donor registration 
program in November, 1979. Under 
the new program, all drivers are 
mailed a brochure which provides a 
donor card and answers questions 
commonly asked about organ do- 
nation. Receiving the flier approxi- 
mately six weeks in advance of their 
license examination, drivers have 
an opportunity to write to the state's 
Human Tissue Donation Program 
for further information. During 
1980, a total of 80,835 citizens reg- 
istered as organ donors. The North 
Carolina Highway Patrol, local law 
enforcement agencies, emergency 
medical service providers, and hos- 
pital emergency department staffs 
are all being informed that an indi- 
cation on the license means that the 
individual carries a donor card. 

At this point, Fd like to call your 
attention to a truly remarkable 
achievement in the field of immuni- 
zation of our children against pre- 
ventable communicable diseases. 

A major impact upon immuniza- 
tion delivery was brought about by 
the General Assembly's action in 
revising the immunization law in 
1979. Because the law required a 
minimum basic series for students 
in kindergarten through 12th grade, 
there were large numbers of junior 

Vol. 42, No. 9 i-n, 



i 



and senior high school students who 
received immunizations. More than 
750,000 doses of vaccine were given 
by local health departments during 
the '79-80 fiscal year. Perhaps a mil- 
lion additional doses were admin- 
istered by our private physicians 
across the state during this intensive 
effort. Immunization assessment 
' data submitted by the public, pri- 
vate and religious schools indicate 
that 98. 1'yf of kindergarten and first 
grade students started school al- 
ready having received the basic 
series of immunizations. While this 
kindergarten and first grade re- 
porting has been conducted annu- 
ally since 1973, this was the first 
year that information on students in 
grades 2-12 was available. School 
reports on these students indicated 
that 9S.49c met minimum immuni- 
zation requirements. 

The year 1 980 was an exciting one 
environmentally for North Caro- 
lina, particularly in the area of haz- 
ardous waste. New programs were 
put into motion at both the state and 
federal levels that will have a sig- 
nificant effect on our environment 
for years to come. Nationally, the 
long awaited Resource Conserva- 
tion and Recovery Act, which was 
designed to help this country safely 
manage its hazardous chemical 
wastes, became the law in every 
state in the union. Here in North 
Carolina, a Governor's Task Force 
on Waste Management conducted 
an eight month study to determine 
how we could best manage our own 
potentially dangerous waste mate- 
rials. The work of that task force, 
which was completed in February, 
has resulted in a bill now before the 
state legislature.* Its purpose is to 
ensure that our hazardous and low- 
level radioactive wastes are safely 
managed in years to come. 

In addition, our own Solid and 
Hazardous Waste Management 
Branch has received federal ap- 
proval to regulate hazardous wastes 
in North Carolina. We are one of 
anly 16 states authorized to enforce 
federal hazardous waste laws at the 
state level. 



*The "Hazardous and Low-Level Radioac- 
tive Waste Management Act of 1981" was 
ratified on June 26, 1981. 



But hazardous waste was not the 
only area where your environmen- 
tal health team made significant 
contributions during 1980. I would 
like to take a few minutes now to 
review with you the progress that 
section has made in environmental 
management during the past 12 
months. 

Our Water Supply Branch is re- 
sponsible for seeing to it that all 
public water supplies provide safe 
drinking water for the populations 
they serve. On March 14, 1980, the 
federal government awarded North 
Carolina primary enforcement re- 
sponsibility to ensure that our 3,000 
community water supplies, every- 
thing from the city of Charlotte to a 
small trailer park, meet the re- 
quirements of the state's Safe 
Drinking Water Act. 

Our Vector Control Branch, 
which is in charge of North Caro- 
lina's Mosquito Control Program, 
also was active in 1980. In August, a 
cooperative survey involving the 
state, the Centers for Disease Con- 
trol, and six local health depart- 
ments was initiated to determine the 
extent to which Aedes aegypti mos- 
quitoes are breeding within the 
state. These mosquitoes have be- 
come increasingly important in the 
Southeastern United States since 
they are the vectors for dengue 
fever, a viral disease. The spread of 
dengue has been monitored closely 
by CDC personnel in the Caribbean 
and northern Mexico. The first re- 
port of dengue transmission in the 
Continental United States since 
1945 occurred in Brownsville, 
Texas, last fall (September, 1980). 
North Carolina had one reported 
case of imported dengue. In addi- 
tion to its disease vector potential, 
Aedes aegypti are often trouble- 
some pests, apparently preferring 
the blood of man to that of other 
animals. Being a semi-domesticated 
species, breeding is almost ex- 
clusively in artificial containers in 
and around human habitation. 

Urban centers surveyed in 1980 
by local health department person- 
nel were Charlotte, Durham, Fay- 
etteville, Greensboro, Wilmington 
and Winston-Salem. The informa- 
tion gained from the fall survey re- 
sults show that Aedes aegypti is 



present in the Southern half of the 
state and at population levels suffi- 
cient to support dengue transmis- 
sion if the disease were to become 
established in the state. 

As you may know, the Mosquito 
Control Program provides technical 
and financial aid to local govern- 
ments that operate programs to re- 
duce mosquito populations within 
their areas. Last spring, a "Blue 
Ribbon Committee" was appointed 
by the state health director to de- 
termine how the Mosquito Control 
Program could be improved, to 
better protect the health of the peo- 
ple of this state. More emphasis 
now is being placed on mosquito 
species, their breeding habitats, and 
the best methods of control. This 
study should result in a beneficial 
effect on the level of services that 
are provided at both the state and 
local levels. 

Our Sanitation Branch is the lead 
office for the management of sev- 
eral important public health related 
programs, including shellfish, milk, 
food, lodging, institutional sanita- 
tion and wastewater and individual 
waste supply systems. 

Since shellfish are often eaten 
raw or partially cooked, shellfish 
waters must meet strict microbio- 
logical standards, and processing 
and handling must be closely mon- 
itored if health problems are to be 
avoided. The Sanitation Branch in- 
spects on a regular basis shellfish 
processing and handling plants, and 
analyzes shellfish waters to detect 
any potential health problems. 
There are currently 327,323 acres 
on our coast closed to shellfish har- 
vest. Closures are made when 
bacterial counts exceed the stan- 
dard and to provide buffer zones in 
the vicinity of sewage treatment 
plan outfalls. 

Health problems that can occur if 
restaurants, motels, or institutions 
are not properly managed also are a 
major concern of the Sanitation 
Branch. Thousands of food estab- 
lishments and places of lodging are 
inspected each year to guarantee 
that they are operated in a sanitary 
manner. Grade "A" milk producers 
and pasteurization plants likewise 
are inspected and certified. 

Regulation of septic tank systems 



September 1981, NCMJ 



657 



continues to be a major activity of 
the Sanitation Branch staff and over 
500 local public health sanitarians. 
With approximately 39,000 septic 
tanks installed in 1980 requiring 
over 107,000 site inspections. North 
Carolina continues to be among the 
leading states in septic tank instal- 
lations. An emphasis on soil and site 
evaluation procedures rather than 
just percolation tests to determine 
suitability for ground absorption 
systems has significantly reduced 
failure rates across the state. How- 
ever, problem areas such as one 
county with failures estimated at 
approximately 359f . or 5,000 septic 
tank systems, indicate that state and 
local efforts must be intensified if 
we are to protect our surface and 
groundwaters from degradation. 

The Sanitation Branch, through 
the research efforts of N.C. State 
University and the University of 
North Carolina at Chapel Hill, 
completed in March 1981 a two-year 
study related to the movement of 
bacteria, virus, and nutrients from 
septic tank systems, in selected 
coastal plain soils. This study points 
out vividly that septic tank systems 
will perform very satisfactorily 
where they are properly sited but 
will create both health and en- 
vironmental hazards if installed in 
wet soils. 

As I mentioned earlier, calendar 
year 1980 was the most active so far 
for North Carolina's Hazardous 
Waste Management Program. Each 
year approximately 120 million 
gallons of hazardous waste and 
200.000 cubic feet of low-level 
radioactive waste are generated in 
North Carolina in the process of 
meeting its citizens" demands for 
modern day goods and services. 
North Carolina ranks as the 11th 
largest generator of hazardous 
waste and the fourth largest gener- 
ator of low-level radioactive waste 
in the nation. Thanks to the hard 
work of the Solid and Hazardous 
Waste Management Branch, ours 
was one of the first states in the 
nation and the very first in the south 
to receive interim authorization to 
administer the federal Resources 
Conservation and Recovery Act 
(RCRA). Under interim authoriza- 
tion North Carolina, not the federal 

658 



government, is responsible for en- 
forcing a waste monitoring system 
that tracks hazardous waste from its 
point of generation to its ultimate 
disposal (or from "'cradle to 
grave""). This system ensures that 
all waste generators are complying 
with federal and state laws and that 
they are disposing of their wastes in 
a safe manner. In addition to in- 
specting industries to make sure 
they are operating in compliance 
with standards set up under RCRA, 
the Solid and Hazardous Waste 
Management Branch provides 
technical assistance to generators. 

We are now actively seeking ap- 
proval from the Environmental 
Protection Agency (EPA) to issue 
permits for hazardous waste and 
treatment facilities. This approval 
should come later this year. Within 
three years, the state hopes to have 
permanent authorization from the 
EPA to manage all hazardous waste 
activity in North Carolina. The task 
is a massive one. As of January of 
this year, more than 1 ,000 industries 
in North Carolina were listed by the 
EPA as large generators of hazard- 
ous waste. Large generators are 
those industries that produce more 
than a ton of hazardous waste per 
month. According to information 
supplied by the EPA. North Caro- 
lina has 1.362 large generators of 
hazardous waste: 325 transport- 
ers of hazardous waste: and 654 
treaters. storers. or disposers of 
hazardous waste. All generators, 
transporters, treaters. storers and 
disposers will have to be closejy 
regulated by the Solid and Hazard- 
ous Waste Management Branch. 
The 1 ,362 generators listed with the 
EPA include 872 different com- 
panies that employ 362.000 people 
and have an annual payroll of $5 
billion. 

Also vital to the state"s Hazard- 
ous Waste Management Program is 
the passage of the Hazardous and 
Low-Level Radioactive Waste 
Management Act of 1981. now 
being debated by the North Caro- 
lina General Assembly. This bill 
was introduced by Governor Hunt 
after eight months of study by a spe- 
cial Governor's Task Force on 
Waste Management. It is designed 
to enable North Carolina to safely 



and effectively manage its hazard- 
ous and low-level radioactive 
wastes. The three most important 
parts of the bill call for (1) estab- 
lishing a waste management board 
that will continue to seek solutions 
to hazardous waste problems, and 
advise the governor on waste man- 
agement issues: (2) granting to the 
governor the power of limited pre- 
emption: (this will allow the gover- 
nor to override arbitrary local zon- 
ing ordinances, in certain cases, if 
these ordinances are designed to 
prohibit the siting of waste man- 
agement facilities) and (3) granting 
the state the power to condemn 
land, with the approval of the coun- 
cil of state, for hazardous waste 
management facilities. 

One of the most worrisome areas 
of concern for us as it surely must be 
for all publicly-supported human 
service programs is that of the 
availability of future funding. In the 
spring of 1981, the Division of 
Health Services is facing a series of 
fiscal crises, the final outcome of 
which — though still unknown — 
will surely mean drastic changes in 
the administration of public health 
programs in North Carolina. 

In fiscal year 1981, the division's 
budget (including Lenox Baker and 
McCain Hospitals) totaled $124.6 
million, of which $50.5 million was 
appropriated by the General As- 
sembly, $62 million was from fed- 
eral funding sources, and $12.1 
million was from non-federal re- 
ceipts. Budgeted expenditures in 
1981 include approximately $36.7 
million to local health departments 
for support of locally delivered 
programs and services. Another $16 
million is budgeted in line-items that 
purchase physicians' care, hos- 
pitalizations, drugs and appliances 
for eligible patients in the various 
purchase-of-care programs in the 
private sector. 

The anticipated cuts in the federal 
budget could significantly reduce 
support to providers at all levels. 
Most programs' budgets depend 
heavily on federal funding. Cur- 
rently, the news from Washington is 
that most federally-funded health 
programs will be consolidated into 
two or three block grants and will be 
reduced by 25%. The basic block 



Vol. 42, No. 9 



I 



grant that has traditionally provided 
general funding for local depart- 
ments — title 314 (d) — may be 
budgeted at zero in 1981-82, result- 
ing in a $1.6 million loss to North 
Carolina in that funding source 
alone. 

In addition to the grim future the 
division faces as a result of federal 
reductions, shortfalls in state rev- 
enue have compounded the re- 
source dilemma. Early in the cur- 
rent legislative session, the Division 
of Health Services had to identify 
$455,000 worth of state-funded po- 
sitions to be abolished July 1 . An 
additional 30 positions in regional 
offices are also slated for abolition 
in an effort to bring the state budget 
into line. All reductions have been 
accomplished by reducing state 
personnel and administrative costs 
— avoiding cuts to local health de- 
partments and to other direct ser- 
vice providers. The division is 
committed to approaching further 



cuts with the same goal that has 
guided us so far — minimizing re- 
ductions in direct service to the de- 
gree possible. 

Every one of the programs men- 
tioned in this report as well all the 
others precluded from discussion 
by time require and seek the 
steadying hand of support and the 
expertise of North Carolina medical 
practitioners. To emphasize that 
point, let me close by offering the 
words this society heard from state 
health director Charles O. Laugh- 
inghouse of Greenville, himself, in- 
cidentally, at the time, a former 
president of the North Carolina 
Medical Society. In 1926. exactly 55 
years ago, he said. "An intimate ac- 
quaintanceship with the problems, 
satisfactions, dissatisfactions, plea- 
sures, pains, purposes and emolu- 
ments of medical men, through the 
actual doing of their day's work, has 
begotten in the heart of your execu- 
tive officer a deep regard, a sense of 



companionship in arms, a consider- 
ation, a respect for, and above all, a 
loyalty to the medical profession 
which will force him to keep an un- 
divided faith with medical men in 
active practice in North Carolina. 
May he ask your assistance? May 
he depend upon your indulgence? 
May he feel the protection and the 
confidence which should abide with 
him through your patient coopera- 
tion? May he remind you now that 
the problems of infection and con- 
tagion are fairly well in hand; that 
the other diseases of infancy, child- 
hood, youth, middle age, and senil- 
ity can be handled in no way save 
through the alliance of the board of 
health and the entire profession of 
the state. Medical advancement has 
brought us to where there can be no 
parting of the ways. Preventive 
medicine and curative medicine, 
public health workers and private 
practitioners must all hang together 
or they will hang separately." 



Since 1916, Saint Aibans Psyctniatric Hospital lias been 
buiiding on a tradition of quaiity care for adults and adolescents. 
A private, nonprofit hospital. Saint Albans is dedicated 
to meeting the unique needs of each patient. 

THEFlTTURECOMESmST. 



In 1980, Saint Albans 
opened a $7,8 million 
building with 162 beds 
and all clinical facilities. 
Our expanded programs 
include adults, adoles- 

Emergency services 
available at all times. 



cents, substance abuse, 
and geriatrics. We are 
also studying expansion 
in other areas as v\/e 
prepare for a new era of 
service, 

ROLFE B. FINN, M.D. Medical Director 
ROBERT L. TERRELL, JR. Administrator 



Saint AlbansPsychiatric Hospital 

P.O. Box 3608 Radford, Virginia 24141 



September 1981, NCMJ 



659 



National Institutes 
Of Health 



COMMENT: 

In a recent issue of this journal, 
our reasons for not publishing a con- 
sensus report from the National In- 
stitutes of Health were given. Now we 
have received another such report 
which is certainly better done and of 
considerable potential value to our 
readers. Testing for cancer antigens 
promises to become more frequent 
and more widespread and therefore 
more costly in the near future. 
Tumor markers currently under in- 
vestigation in cancer diagnosis and 
follow-up include /^-glucuronidase, 
breast-cyst fluid protein (BCFP), 
colon mucoprotein antigen (CMA), 
colon-specific antigen (CSAP), 
galactosyl transferase isoenzyme-II 
(GT-II), pancreatic oncofetal antigen 
(POA), prostate-specific antigen 
(PSA), and zinc glycinate marker 
(ZGM). CEA, the subject of this dis- 
course, is the only such marker ap- 
proved for use by the FDA but many 
drug houses currently have assays 
waiting to be blessed including 
sialoglycoprotein, human poly- 
peptide antigen (TAP), a-fetoprotein 
(AFP), and B-protein. Maugh (Sci- 
ence 211:909-910, 1981) reports that 
a world market approaching $2 bil- 
lion for such kits may be with us by 
1990. Not only will we be testing for 
antigens then, but we will be also 
stressing our clinical judgment and 
memory if we are offered such a sur- 
feit of diagnostic riches. , „ c. 

J.H.r . 

NATIONAL INSTITUTES 
OF HEALTH 

CONSENSUS DEVELOPMENT 
CONFERENCE STATEMENT 

CEA (CARCINOEMBRYONIC 

ANTIGEN): ITS ROLE AS 

A MARKER IN THE 

MANAGEMENT OF CANCER 

A Consensus Development 
Conference was held at the National 



Institutes of Health Sept. 29-Oct. I . 
1980, to address issues concerning 
the role of the carcinoembryonic 
antigen (CEA) as a marker in the 
management of cancer. 

At NIH. Consensus Develop- 
ment Conferences bring together 
biomedical research scientists, 
practicing physicians, consumers, 
and others with special interest or 
knowledge, in an effort to reach 
general agreement on the scientific 
evaluation of a medical technology. 
That technology may be a drug, de- 
vice, or laboratory, medical, or sur- 
gical procedure. 

For this Consensus Conference, 
the members of the panel were lim- 
ited to biomedical and clinical in- 
vestigators actively working in the 
field, clinically involved in patient 
care, and familiar with the technol- 
ogy under assessment. The panel 
met following formal presentations 
and discussions to assess the issues 
based on the evidence presented. 
This summary is the result of the 
panel's deliberations. 

INTRODUCTION 

Human neoplasms may produce 
and release into the circulation a 
variety of substances collectively 
referred to as tumor markers. The 
oncofetal antigens comprise one 
particular group of markers, of 
which the carcinoembryonic anti- 
gen (CEA) has been the most widely 
studied. 

CEA is a glycoprotein of about 
200,000 molecular size. It is ex- 
pressed in significant amounts dur- 
ing embryonic life, especially by the 
large intestine, and postnatally by 
carcinomas arising from this site. 
CEA can be released into the circu- 
lation by these tumors and may be 
measured by sensitive radioim- 
munoassay and related techniques. 
Such methods have, however. 



demonstrated that small amounts of 
CEA are also present in the normal 
adult large intestine and in the blood 
of healthy subjects. 

Subsequent investigations have 
revealed that many epithelial 
tumors at other sites may also ex- 
press CEA and be associated with 
elevated plasma concentrates. 
Thus, it may be that the assay of 
plasma CEA has protean applica- 
tions in oncology. 

The Consensus Development 
Panel and members of the audience 
considered evidence to address the 
following questions: 

1 . Should CEA be used in cancer 
screening? 

2. Is CEA helpful in cancer diag- 
nosis? 

3. What does CEA tell about the 
extent and outcome of cancer? 

4. Is CEA helpful in monitoring 
cancer treatment? 

PLASMA CEA LEVELS IN 
HEALTH AND DISEASE 

Using the available radioim- 
munoassay, 2.5 ng/ml is stated to be 
the upper limit of normal for plasma 
CEA levels. Values in excess of 2.5 
ng/ml may be found in association 
with cancers, in particular those of 
the gastrointestinal tract, pancreas, 
ovary, lung and breast. Similarly 
raised CEA levels may be detected, 
however, in cigarette smokers, in 
patients with benign neoplasms, 
and in 159f to 209?^ of subjects with 
inflammatory disorders such as ul- 
cerative colitis, Crohn's disease, 
pancreatitis, liver disease and pul- 
monary infections. Thus, raised 
plasma CEA values are not specific 
for cancer, although very high val- 
ues (for example, above 20 ng/ml) 
are strongly suggestive of malig- 
nancy. It is important that serial as- 
says of CEA be used in reaching a 
clinical judgment, and not any 



i 



660 



Vol. 42, No. 9 



h vhro data show 



/ir 


i^n\ 


/J 













colin 

ih tablet contains 324 mg aspirin, 225 mg magnesium 



kabonate and 200 mg calcium carbonate. 



las greater 
iicid-neutralizing 
effectiveness than 
Ascriptin"A/D 

lEOLIN contains two proven effective acid- 
nutralizers, magnesium carbonate and calcium 
( rbonate. 



' /icriptin A/D, on the other hand, is formulated 
'^^ vth magnesium hydroxide and aluminum hydroxide, 
/uminum hydroxide has been reported to be a 
f orly effective acid-neutralizer.' Additionally, 
c/ing of this particular buffer, as must be done 
f' tablet use, alters its structure, further reducing 
ctacid efficacy.^ 



It is not suprising, therefore, that NEOLIN proved superior 
to Ascriptin A/D in two separate in vitro tests* designed to 
evaluate the acid-neutralizing capacity of buffered aspirin. 
These studies showed that NEOLIN had 1 7.2% to 48.2% 
greater acid-neutralizing capacity than did Ascriptin A/D. 





fast 1 Total Acid-Neutralizing Capacity (mEq 






Neolin 16.9 














Ascriptin A/D 11.4 










1 





rest II Total Acid-Neutralizing Capacity (mEq) 






Neolin 17.0 














Ascriptin A/D 14.5 










1 



Harvey, S.C: "Gastric antacids and digestants," in Goodman, L.S. 
and Gilman, A. (eds): Pharmaceutical Basis of Therapeutics, The, 
ed 6, New York; Macmillan Publishing Co., Inc., 1980, p 991 . 
Garnett, W.R.: "Antacids," in Apple, W. (ed); Handbooi< of 
Nonprescription Drugs, ed 6, Washington, D.C.: American 
Pharmaceutical Association, 1979, p 6. 

'Bristol-Myers Test Method designed to evaluate the acid- 
neutralizing capacity of buffered aspirin preparations using single 
tablet samples of NEOLIN and Ascriptin A/D. Each product stirred 
for 1 5 minutes in an excess of 0. 1 N HCI at 25 °C (Test I) and 
37 °C (Test II) and back titrated with NaOH to pH 2.8. 



IISTOL-MYERS 



m 



PROFESSIONAL PRODUCTS 



in vh/o data show 






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^ 



^^-e^ 



^ 







\ 



With greater acid-neutralizing capacity, 



Ncolin 

gets relief into 
circulation 
faster than 
Ascriptin* A/D 

When salicylate blood levels of NEOLIN and 
Ascriptin A/D were compared in three separate 
crossover studies, total amounts were found to be 
higher for NEOLIN up to one hour after ingestion. 
(Volunteers took 2 five-grain tablets of either 
medication.) More rapid absorption with NEOLIN 
means more rapid availability for pain relief, par- 
ticularly important to patients with osteoarthritis. 



Total Salicylate mcg/ml plasma 



Neolin 



Ncolinthe 

Each capsule-shaped, scored tablet contains 324 mg 
aspirin, 225 mg magnesium carbonate and 200 mg 
calcium carbonate. 




aspirin for today— and every c( 



© 1981 Bristol-Myers Company 



h\ 



-- ^ 



«i 



single determination. The panel be- 
lieves that each laboratory per- 
forming CEA assays should estab- 
lish its own "norma!" range. The 
recommended upper level of "nor- 
mal" (2.5 ng/ml) in the population 
requires additional evaluation. Val- 
ues cited here are based on the only 
radioimmunoassay commercially 
available at the time of the confer- 
ence, the Hoffman- La Roche assay. 
Other assay systems may give dif- 
ferent results. 

CONCLUSIONS AND 
RECOMMENDATIONS 

1. Should CEA he used in cancer 
screening? 

Studies to date have revealed a 
major overlap in the distribution of 
plasma CEA values in subjects with 
inflammatory diseases and benign 
and malignant tumors of the gas- 
trointestinal tract and of other 
sites, including breast, bronchus, 
urothelium, ovary, uterus and cer- 
vix. Therefore, the plasma CEA 
assay does not possess the sensitiv- 
ity (true-positive rate) or the 
specificity (true-negative rate) re- 
quired to discriminate between 
localized malignant tumors and be- 
nign disorders. Consequently, these 
data, together with the fact that 
CEA levels may be elevated in 
smokers, vitiate the use of plasma 
assays in the screening of an 
asymptomatic population to the 
presence of neoplastic disease. The 
use of CEA to assist with the sur- 
veillance of so-called high-risk 
groups, in whom CEA-producing 
tumors may develop, remains to be 
established. 

2. Is CEA helpful in cancer diag- 
nosis? 

Few prospective studies have 
been done to determine whether 
plasma CEA measurement would 
help to confirm a suspected malig- 
nancy in symptomatic patients. In 
addition, caveats with respect to 
cancer specificity which limit the 
test's applicability for screening 
(raised levels occurring with smok- 
ing, non-neoplastic diseases, and 
benign tumors) are also pertinent in 
relation to diagnosis in a symp- 
tomatic population. Therefore, we 
cannot recommend, based on cur- 
rent data, that CEA be used inde- 

September 1981. NCMJ 



pendently to establish a diagnosis of 
cancer. However, in a patient with 
symptoms, gross elevation, greater 
than 5-10 times the upper limit of the 
reference normal range for that par- 
ticular laboratory, should be con- 
sidered strongly suggestive of 
cancer in that particular patient. 
Further diagnostic efforts are ob- 
ligatory. 

3. What does CEA tell about the 
extent and outcome of cancer? 

Many workers have shown that 
preoperative plasma CEA levels 
correlate with the clinical stage of 
disease in several tumor types. Pa- 
tients with colorectal or possibly 
bronchogenic carcinomas whose 
preoperative CEA levels are in the 
lower range have better survival 
rates than patients whose levels are 
above 10 ng/ml. The correlation 
between increasing plasma CEA 
levels and progressive cancer is not 
always exact and a normal CEA 
cannot be taken as evidence of 
localized disease or remission. 
About 15% to 20% of patients with 
proved malignancies never have 
elevated plasma levels. Such false 
negatives may be related to the de- 
gree of tumor differentiation. For 
example, elevated CEA levels 
occur less often with poorly differ- 
entiated than with well differ- 
entiated colorectal carcinomas. On 
the basis of available data, we rec- 
ommend that plasma CEA be mea- 
sured preoperatively in patients 
with either colorectal or bron- 
chogenic carcinomas and be used as 
an adjunct in clinical and pathologi- 
cal staging. 

4. Is CEA helpful in monitoring 
cancer treatment? 

The regular and sequential assay 
of plasma CEA is the best non- 
invasive technique for postopera- 
tive surveillance of patients to de- 
tect disseminated recurrence of 
colorectal cancer currently avail- 
able. CEA has been found to be ele- 
vated when residual disease is pres- 
ent or is clinically progressing. 
Following complete excision of 
such a malignancy, an elevated 
plasma CEA value usually returns 
to normal by six weeks. Failure of a 
reduction of an elevated preopera- 
tive CEA titer strongly indicates the 
presence of residual tumor. CEA 



values often become elevated be- 
fore metastatic disease can be de- 
tected by clinical or other diagnostic 
measures. This information can be 
best obtained by measuring plasma 
CEA preoperatively, four to six 
weeks postoperatively, and at reg- 
ular intervals thereafter. While 
slowly rising values may be more 
indicative of local recurrence, 
rapidly rising values, particularly in 
excess of 20 ng/ml, are found most 
often with hepatic and osseous 
metastases. 

For patients with metastatic 
tumor, the CEA assay may com- 
plement standard clinical measure- 
ments of tumor response to therapy. 
However, as in the case of other 
laboratory tests, there may be dis- 
cordance between observed change 
in tumor mass and corresponding 
CEA values. In patients with ad- 
vanced unmeasurable tumor, espe- 
cially colorectal carcinoma. CEA 
assays may offer the only index of 
change in tumor burden. Although 
definite criteria to aid determining 
therapy in patients with unmeasur- 
able tumor, based on serial CEA 
determinations, are not established, 
it appears that a steadily, markedly 
rising titer is indicative of a poor 
therapeutic response. It is impor- 
tant to remember that raised values, 
due to various causes such as 
smoking, intercurrent infection, 
etc., can be seen in patients with 
clinically stable tumors and that de- 
creasing CEA values are not invari- 
ably a sign of successful therapy. 
Furthermore, a proportion of pa- 
tients with recurrent or advanced 
colorectal cancer may not show 
elevated plasma CEA values. 

The role of CEA in the post- 
operative and therapeutic monitor- 
ing of patients with other types of 
cancer, such as pancreatic, gastric 
and gynecological neoplasms, is 
less convincing. In patients with 
breast malignancies or pulmonary 
cancer, especially small cell car- 
cinoma of the lung, who present 
with significant elevations of CEA, 
changes in CEA titer may be of 
value in assessing response to che- 
motherapy. 

The panel would like to stress that 
the clinical utility of a tumor marker 
may be related to the efficacy of a 

663 



therapeutic regimen. Where earlier 
recognition of disease progression 
does not result in more effective 
therapy, no benefit is gained. On the 
other hand, as more successful 
treatments for the major tumor 
types become available, CEA and 
other tumor markers will be more 
useful in the management of cancer. 

Additional Needs 

The panel has identified several 
areas for future study which should 
improve the clinical utility of the 



CEA assay: the improvement of 
assay methodology: the evaluation 
of monoclonal antibodies to CEA 
for improving assay specificity: the 
establishment of a laboratory qual- 
ity control system using a CEA 
standard preparation: the clinical 
study of CEA in combination with 
other markers: the diagnostic role of 
CEA in biological fluids other than 
plasma: the individual and collec- 
tive comparison of CEA with other 
specific diagnostic modalities: the 
estimation of tumor CEA content in 
relation to plasma CEA values: and 



the study of the pathophysiology 
and metabolism of CEA. 



The Consensus Conference was sponsored by the Na- 
tional Cancer Institute, assisted by the Office for Medical 
Applications of Research. Office of the Director. NIH. 

Members of the panel: David M. Goldenherg. Sc.D.. 
M.D.. (Chairmanl. University of Kentucliy Medical Center. 
Lexington. Ky.; A. Munro Neville. M.D.. Ph.D.. Ludwig 
Institute for Cancer Research, Sutton. Surrey, England; 
■Anne C. Carter. M.D.. State University of New York 
School of Medicine. Brooklyn. N.Y,. Vay Liang W. Go. 
M-D,. Mayo Clinic. Rochester. Minn.; Edward Douglas 
Holyoke. M.D.. Roswell Park Memorial Institute. Buffalo, 
NY,; Kurt J. Isselbacher, M.D., Massachusetts General 
Hospital. Harvard Medical School. Boston, Mass.; Philips. 
Schein. M.D., Vincent T, Lombardi Cancer Research Cen- 
ter. Georgetown University Medical Center. Washington, 
D.C; Morton Schwartz, Ph.D.. Memorial Sloan-Kettering 
Cancer Center. New York. N.Y. 

Conference Organizers: K. Robert Mclntire. M,D, and 
Louis P. Greenberg. M.S., National Cancer Institute. 
Bclhesda, Md, 



The invariable antecedence of the cause, and consequence of the effect, ascertained from 
many clear and decided observations, are then the principal circumstances to be regarded in 
determining their nature. These apply to the dead as well as to the living worlds: but as the 
complexity of the phenomena of the human system is greater than that of surrounding nature: 
since it consists of masses of organs, each operating on the other, together, and on each 
other, for a specific purpose, the health and preservation of the whole, it is evident that in 
proportion to the number of these organs must be the variety produced in the phenomena 
presented by the causes which derange the system, and the danger of confusion in consider- 
ing them. 

In the sensible phenomena, which are considered by natural philosophy and chemistry, the 
case is widely different; if one body is propelled against another, immediate motion, if the 
power is sufficient, is the result; if one planet approaches another, they mutually move 
towards each other, and the effect is immediate, proportioned to their distance; if two 
chemical bodies which have an attraction for each other are put into the same menstruum, 
they act at once upon each other, and the phenomenon there ends. 

In every respect, both with regard to the shortness of the time intervening between the 
cause and effect, as also with regard to the simplicity of the phenomena, which follow the 
action of causes, there is less obscurity in the inanimate, than in the living world. In health 
and disease, there is in the living body a regular series of changes, which follow each other in 
stages, each of which may present a vast variety of phenomena, whose varying features have 
not yet been recorded: thus, as in the healthy system, the periods of youth, maturity, and 
decline, succeed each other, each characterized by its appropriate susceptibilities; so in 
disease there is the same succession of stages: thus, in common inflammation, heat, pain, and 
redness, form the first: pus characterizes the second, ulceration the third, and the process of 
healing, the last stage; in the erysipelatous species, heat, pain, and redness, the secretion of 
water, and lastly, branny scales. In fevers generally, the cold, the hot, and the sweating 
stages, form the succession. In each of these, however, there is some variety; common 
inflammation may be arrested, and terminate in resolution, or instead of forming pus. it may 
end in scirrhus or in gangrene. Erysipelas, instead of being followed by blisters and scales, 
may also terminate in mortification. The causes of these deviations, however, can sometimes 
be appreciated; thus, a plethoric and irritable state of the system, may produce mortification, 
in an inflamed part, or the quantity of the poison absorbed may produce a fever in which a 
chill does not appear, the hot stage commencing the attack. The regular order, however, of 
almost every disease, is characterized by a commencement, maturity and decline, and this 
general feature appears to pervade all the operations of the system. — Elements of the Theory 
and Practice of Physic, by George Gregory, M.D., with notes and additions, adapted to the 
Practice of the United States, by Nathaniel Potter, M.D., and S. Colhoun, M.D. Vol. I, 
Philadelphia, Towar & Hogan, 1829. 



664 



Vol. 42. No. 9 



Correspondence 



ACETAMINOPHEN POISONING 

To the Editor: 

In the article "Toxic Encounters of the Dangerous 
Kind — Acetaminophen Poisoning," March 1981. 
North Carolina Medical Journal, it is stated that 
"N-acetylcysteine has not been approved by the FDA 
for use as an antidote in the poisoning (of 
acetaminophen): Supervision can be obtained by 
calling the Rocky Mountain Poison Center toll-free 
1-800-525-6115." 

This is indeed a true statement. However, the main 
reason to call this number is to put the patient on the 
protocol for additional cases in the new drug applica- 
tion to the FDA. This drug can be used without notifi- 
cation of the Rocky Mountain Poison Center and is 
indeed used without notification on the recommenda- 
tion of most of the poison control centers in this coun- 
try. When a physician feels the drug needs to be given, 
informed consent is all that is necessary. If there are 
any questions as to the use of N-acetylcysteine 
(Mucomyst) or the treatment of acetaminophen 
poisoning in general, any physician may call the Duke 
Poison Control Center, 919-684-81 1 1. We will be glad 
to advise and supervise in the use of this antidote and 
in the treatment of this poisoning. 

Shirley K. Osterhout. M.D. 
Director. Duke Poison Control Center, and 
Assistant Professor of Pediatrics, 
Duke University Medical Center 
Durham, N.C. 27710 

To the Editor: 

In response to Dr. Osterhout' s letter concerning my 
article about acetaminophen poisoning. I feel strongly 
that practitioners in this state should continue to call 
the Rocky Mountain Poison Center before adminis- 
tering N-acetylcysteine. I say this for the following 
reasons: 

1) This antidote for acetaminophen overdose has 
not been approved by the FDA for this purpose. The 
Rocky Mount Poison Center, under the direction of 
Dr. Barry Rumack and his group, has the IND (inves- 
tigational new drug) for this drug. They have the pro- 
tocol for the antidote's use. 

2) The Rocky Mountain group has amassed 4,900 
cases of acetaminophen overdose and has more ex- 
perience with this drug and the antidote than any other 
group in the United States. They have diligently col- 
lected these data about this poisoning and its treat- 
ment for the health care professionals in the United 

September 198L NCMJ 



States. We owe them something in terms of adding to 
their data base. 

3) The McNeil Consumer Products Company (mak- 
ers of Tylenol) states: "Since Mucomyst (N- 
acetylcysteine) has not been approved by the FDA for 
use as an antidote, except as an investigational drug, 
supervision must be obtained by calling the Rocky 
Mountain Poison Center's toll-free number 800-525- 
6115." 

4) In Emergency Medicine.^ the renowned tox- 
icologist Dr. Alan Done states: "Since this use (N- 
acetylcysteine) is still experimental, it's preferable to 
give the drug under a protocol and an Investigational 
New Drug exemption: for which supervision is pro- 
vided by the Rocky Mountain Poison Center. . . ." 

5) In Pediatrics in Review- (a continuing education 
journal for pediatricians sponsored by the American 
Academy of Pediatrics), Drs. F. Lovejoy and Peter 
Goldman (from the Harvard Medical School) state 
that practitioners should call the RMPC for direction 
and protocol inclusion. 

6) In Hospital Physician.'^ Dr. Goldfrank and Kirs- 





B.B. Plyler, Jr.. C L.U. 



Breni Plyler. C.L U 



— Medical Clinics Only — 

High limit group Life and Disability Income 
insurance. Available only to medical clinics 
and their employees (not available to general 
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P.O. Box 576 'Wilson, N.C. 27893 

Telephone (919)291-3333 



665 



tein offer the same advice in their article in 
acetaminophen toxicity. 

7) In March 1981, in Denver when I asked Dr. Barry 
Rumack when the FDA was going to approve N- 
acetylcysteine for antidote use, he replied that he had 
no idea. 

I believe that we should continue to communicate 
with the group with the most experience with this 
poisoning so that we can help them as they have 
helped us. We at Bowman Gray School of Medicine, 
Pediatrics Department, would also be happy to be of 
assistance to health care personnel in the state who 
need information concerning acetaminophen poison- 
ing and its treatment. 

Ronald B. Mack, M.D. 
Associate Professor of Pediatrics 
Bowman Gray School of Medicine 
Winston-Salem, N.C. 27103 



References 



1. Done A: The toxic emergency — dealing ' 
Med 13:83-90. 1981. 



.ilh 



iceiaminophen overdose. Emergency 



2. Lovejoy F.. Goldman P: Acetaminophen toxicity. Pediatr in Rev 1:117-121, 1979. 

3. Goldfrank L, Kirstein R: Acute acetaminophen overdose. Hosp Phys 16:52-60. 1980, 



CAMPHOR POISONING 

To the Editor: 

I want to give a hearty second to Dr. Ronald Mack's 
(North Carolina Medical Journal, April, 1981) 
conclusion that camphor has no place in modern 
medicine and it has to go. The American College of 
Apothecaries is working very hard to persuade the 
FDA to remove camphorated oil and all products 
containing it from the market. Interested physicians 
should write John T. McElroy, Branch Chief, 
Neuropharmacologic and Dermatologic Branch, Di- 
vision of OTC Drug Evaluation, Bureau of Drugs, 
FDA. Rockville, Md. 20857. 

Shirley K. Osterhout, M.D. 
Director, Duke Poison Control Center, and 
Assistant Professor of Pediatrics, 
Duke University Medical Center, 
Durham, N.C. 27710 



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and adolescents 

— An open medical staff with 22 Psychiatrists 

— A consulting medical staff representing all 
specialties 

— Short, intermediate, and long-term treat- 
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needs 

— Psychiatric consultation and hospitalization 
on a 24-hour basis 




Fully accredited by Joint Commission on Ac- 
creditation of Hospitals for adults, children, 
adolescents, and drug-alcohol abuse 
Licensed by the Slate ol North Carolina 
Participants in Medicaid/Medicare Program 



For further information, please contact: 

Mary Donnelly, Administrator 

Dr. Robert L. Green, Jr., Medical Director 

3019 Falstaff Road 

Raieigti, Nortti Carolina 27610 

(919) 755-1840 



666 



Vol. 42, No. 9 



11 




NEW MEMBERS 

of the State Society 



ALAMANCE-CASWELL 

Bowton. David Lowell. (IM) 327 Graham-Hopedale Road. P.O. 
Box 991. Burlington 27215 

Everhart. Clyde Hugh. (PUD) 327 Graham-Hopedaie Road. P.O. 
Bo.x 991. Burlington 27215 

BURKE 

Bukhari. Mustao Ahmad. (IM) P.O. Box 700. Valdese 28690 
Greene. Walter Leith. Jr.. (OBG) 508 Woodbridge Apts.. Morgan- 
ton 28655 
Kath. Philip Douglas. (OPH) 335 E. Parker Road. Morganton 28655 



MECKLENBURG 

Morris. David Perry. 6958 Folger. Charlotte 28211 

Pigg. William Larry. (RESIDENT) 3129 Windsor Drive, Charlotte 

28209 
Whitlock. Gary Thomas. III. (RESIDENT) 1540 Garden Terrace. 

Charlotte 28203 

NEW HANOVER-BRUNSWICK-PENDER 

Presnell. Timothy Andrew. (RESIDENT) 242 Brookview Road. 
Wilmington 28403 

RANDOLPH 

Hanspal. Prithvi Pal Singh. (U) 171 McArthur Street. P.O. Box 
1509. Ashehoro 27203 

WAKE 

Beck. Paul, (IM) 401 Foxhall Drive, Ste. 502. Raleigh 27607 



CARTERET 

Zettl. Matthew Lee, (ORS) 3617 Sunny Drive. Morehead City 28557 

CATAWBA 

'Rudisill, Elbert Andrews, Jr.. (FP) Route 10. Box 695. Hickory 
28601 

COLUMBUS 

Glinski. Ronald Peter. (U) 103 E. Main Street. Whiteville 28472 

DURHAM-ORANGE 

Baker. Ralph Parr, Jr.. (RESIDENT) 2008 W. Club Boulevard. 
Durham 27705 

Bennett. Lawrence North. (STUDENT) 234 Craige Dormitory. 
Univ. of North Carolina. Chapel Hill 27514 

Butler, Wendell DeCamp, (STUDENT) 2509 Englewood Ave.. 
Durham 27705 

Colvard. David Fred. (RESIDENT) Box 3812. Duke Medical Cen- 
ter. Durham 27710 

Glover. Michael Griffin. (STUDENT) 9 Hickory Downs. Five Oaks 
Drive. Durham 27705 

Tyson. George Walter. (NS) UNC. Neurosurgery. Burnett- 
Womack Bldg. 229-H. Chapel Hill 27514 

FORSYTH-STOKES-DAVIE 

Tarlson. Mark Edwin. (STUDENT) 1430 Chelsea Street. 
Winston-Salem 27103 

Kilpatrick Timothy Michael. (RESIDENT) 707 Gales Ave.. 
Winston-Salem 27103 

■Russell, Wilson Glover. (PTH) Forsyth Memorial Hospital. De- 
partment of Pathology. Winston-Salem 27103 

5pillman. Louis Cromwell. (FP) Route 3. Box 315. Winston-Salem 
27105 

■lAYWOOD 

Vlilling. James R.. P.O. Box 398. Hazelwood 28738 

REDELL 

serene, James William. (ORS) 141 N. Kelly Street. Statesville 

28677 

.ENOIR-GREENE 

Vhitaker. Donald Nash. Jr.. (IM) 1201 Woodberry Road. Kinston 
28501 



WHAT? WHEN? WHERE? 

In Continuing Education 



Please note: 1. The continuing Medical Education Programs at 
Bowman Gray. Duke. East Carolina and UNC Schools of 
Medicine, Dorothea Dix. and Burroughs Wellcome Company are 
accredited by the American Medical Association. Therefore CME 
programs sponsored or cosponsored by these schools automatically 
qualify for AMA Category I credit toward the AM.^'s Physician 
Recognition Award, and for North Carolina Medical Society 
Category A credit. Where AAFP credit has been requested or 
obtained, this also is indicated. 

2. The ""place" and '"sponsor" are indicated for a program only 
when these differ from the place and source to write "for informa- 
tion." 

September 9 

""Cancer Day 1981" 

Place: Pitt County Memorial Hospital Auditorium. Greenville^ 

Fee: $50 

Credit: 7 hours. AAFP applied for 

For Information: F. M. Simmons Patterson, M.D.. Assistant Dean 

for Continuing Medical Education. East Carolina University 

School of Medicine, Greenville, N,C. 27834 

September 15 

5th Annual Cape Fear Medical Symposium 

"Update in Infectious Diseases" 

Place: Bordeaux Motor Inn. Fayetteville 

Credit: 7 hours 

For Information: Mrs. Mary Henley. Fayetteville Area Health 

Education Center. P.O. Box 64699, Fayetteville, N.C., 28306 or 

919/323-1152 

September 16 

'"Cardiac Rehabilitation and Consequences of Stress" 
Place: Central Carolina Hospital. Sanford 
Credit: 15 hours 
Fee' $10 

For' Information: R. S. Cline. M.D.. 919/774-4111. Lee County 
Hospital, Sanford 27330 



SEPTEMBER 1981. NCMJ 



667 



September 18 

"Rocky Mountain Spotted Fever" 
Place: Moses Cone Hospital, Greensboro 
Credit: 4 hours 
For information: Fred Levick. 919-379-4025 

September 25-26 

"Dermatology for the Non-Dermatologist" 

Place: Wilmington Hilton 

Credit: 7 hours 

Fee: $50 

For Information: W. B. Wood. M.D., Office of Continuing Educa- 
tion, 231 McNider Building, UNC School of Medicine, Chapel 
Hill 27514 919-933-2118 

September 29-October 1 

"1981 Duke Cardiac Arrhythmia Course" 

Place: Rauch Conference Room. Rm. 15103 — Morris BIdg., Duke 

South 
Credit: 17 hours 
Fee: $175 
For Information: Galen Wagner, M.D.. Box 31211, Duke Univ. 

Med. Ctr., Durham 27710 919-681-2255 

October 1-2 

"Calciton-Biological and Clinical Aspects" 
Place: Velvet Cloak Inn, Raleigh 
Fee: $25 
Credit: 7 hours 

For Information: William Wood, M.D. 231 McNider Building, 
UNC School of Medicine, Chapel Hill 27514 919/933-2118 

October 1-3 

"Natural Abilities and Perceived Worth: Rights. Values and Re- 
tarded Persons" 

12th Symposium on Philosophy and Medicine 

Place: Greenville 

For Information: Loretta Kopelman, ECU School of Medicine, 
Greenville 27834 919-757-4624 



October 1-4 

The 1981 Duke University Invitational Assembly for Advanced 

Urology 
"Diseases of the Lower Urinary Tract" 
Place: Pinehurst Hotel and Country Club 
For Information: David F. Paulson, M.D., Duke Univ. Med. Ctr., 

Durham 919-684-2033 

October 3-4 

"Pediatric-Gynecology and Adolescent Sexuality" 

Place: Wrightsville Beach 

Fee: $125 

Credit: 12 hours 

For Information: William Wood, M.D. 919/933-2118 

October 7-8 

"2Ist Annual Charlotte Postgraduate Seminar" 

Place: Charlotte Memorial Hospital 

Fee: None 

Credit: 12 hrs. 

For Information: C. Whit Blount. Jr.. M.D.. Shamrock Family 

Practice Clinic. 3616 Michigan Avenue, Charlotte. N.C. 28215. 

704-537-6952 

October 7 

"Surgical Update for Primary Care Physicians" 

Place: Pitt County Memorial Hospital Auditorium, Greenville 

Fee: $50 

Credit: 6 hours, AAFP applied for 

For Information: F. M. Simmons Patterson. M.D., Assistant Dean 

for Continuing Medical Education, East Carolina University 

School of Medicine, Greenville 27834 

October 9 

"11th Annual Seminar in Medicine (Hypertension)" 

Place: Bowman Gray School of Medicine 

Credit: 6 hours 

Fee: $60 

For Information: Emery C. Miller, M.D., 300 S. Hawthorne Road, 

Bowman Gray School of Medicine, Winston-Salem 27103 919- 

748-4450 



IF YOUR PATIENT TELLS US 

aBH SHE'S PREGNANT, 
SHE WON'T GET A LECTURE. 
SHE'LL GET HELP. 



Free, professional problem pregnancy counseling. 
If she can't come to us, we'll come to her. 

The Children's Home Society of North Carolina, Inc. 



Asheville (704) 258-1661 Fayetteville (919) 483-8913 

Chapel Hill (919) 929-4708 Greensboro (919) 274-1538 

Charlotte (704) 334-2854 Greenville (919) 752-5847 

Wilmington (919) 799-0655 ja"" 



Member Child Welfare League of America. Founded 1902. 



668 



Vol. 42, No. 9 : 



i 



October 21-22 

"Office Treatment of Depression" 
Place: Carolina Inn. Chapel Hill 
Hee: $20 

For Information: J. Ingram Walker, M.D., Dept. of Psychiatry. 508 
Fulton Street. Durham 27705 919-286-4011, Ext. 6651 

October 22 

"Headache" 

Place: Burroughs Wellcome. Research Triangle Park 

Credit: 4 hours 

Fee: None 

For Information: Mrs. Sandy Foster 919-541-9090 

October 22-23 

"Pediatric Pathology Club" 
Place: Duke Univ. Medical Center 
Credit: 16 hours 
Fee: $120 

For Information: William D. Bradford. M.D., Box 3712, Duke 
Univ. Med. Ctr.. Durham 27710 

October 25-26 

"Technique of Pacemaker Implantation & New Types" 

Place: Bowman Gray School of Medicine 

Credit: 9 hours 

Fee: $60 

For Information: Emery C. Miller, M.D.. 300 South Hawthorne 

Street. Bowman Gray School of Medicine, Winston-Salem 27104 

919-748-4450 

October 30-31 

"Understanding and Treatment of the Aggressive Adolescent" 

Place: Searle Center for Continuing Education, Duke University 
Medical Center 

Credit: 1 1 hours 

Fee: $175 

For Information: J. Ingram Walker. M.D.. Duke University Medi- 
cal Center 919-684-271 1, Ext. 303 

October 30-31 

"14th Annual Malignant Disease Symposium on Abdominal and 

Extremity Tumors" 
Place: UNC School of Medicine 
Credit: 1 1 hours 
Fee: $100 
For Information: Mimi Minkoff. Cancer Research Center, Box 30 

MacNider BIdg., Chapel Hill 27514 

October 31-November 2 
"Advanced Cardiac Life Support Instructors Course" 
Place: Bowman Gray School of Medicine 
Credit: 22 hours 
Fee: $300 
For Information: Emery C. Miller. M.D., 919-748-4450 

November 6 

"Alumni Scientific Sessions" 

Place: Bowman Gray School of Medicine 

Credit: 6 hours 

Fee: None 

For Information: Emery C, Miller. M.D. 919-748-4450 

November 20-23 

"Multiple Sclerosis for Practicing Physicians" 
M Place: Duke University Medical School 
Credit: 9 hours 
Fee: $10 
For Information: Allen D. Roses. M.D. 919-683-6274 



DM CONTIGUOUS STATES 

September 3-4 

"Advances in Clinical Nutrition" 

Place; Sea Pines Resort. Hilton Head Island, South Carolina 
For Information: Julie Bishop, A. S. P.E.N. , Suite 810. 1025 Ver- 
mont Avenue. N.W.. Washington, D.C. 20005 202-638-5881 

September 25 
"Environmental Insults to the Fetus and the Newborn" 
Place: Richmond Hyatt. Richmond, Va. 
For Information: Kathy E. Johnson 804-786-0494 

September 1981, NCMJ 



October 30-31 

"Allergy and Immunology for the Clinician" 
Place: Hyatt-Hilton Head Island. S.C. 
Credit: 14 hours 

For Information: A.J. Kimber. American Academy of Allergy. 61 1 
East Wells Street. Milwaukee. WI 53202 414/272-6071 

The items listed in the above column are for the six months 
immediately following the month of publication. Requests for listing 
should be received by "WHAT? WHEN? WHERE?". P.O. Box 
27167. Raleigh 2761 1. by the 10th of the month prior to the month in 
whichthey are to appear. A "Request for Listing" form is available 
on request. 



AUXILIARY TO THE NORTH CAROLINA 
MEDICAL SOCIETY 



AMA AUXILIARY 1981 CONVENTION 
June 7-10, 1981 

National AMA Auxiliary leaders have the perfect 
recipe for a successful meeting — excellent and 
stimulating speakers, good workshops and time for 
talk, important business, fun and fine food and lodging 
— carefully blended and carefully timed. Everyone 
could recognize a growing sophistication and deter- 
mination as 343 national and state delegates gathered 
to do the business of our organization. 

Eighteen delegates, alternates and guests, including 
Mona Sauls, our new Executive Secretary, ably rep- 
resented North Carolina in Chicago, June 7-10. These 



PULMONARY DIAGNOSTIC 
TESTING 

FROM ROUTINE SPIROMETRY 
TO COMPLETE PULMONARY 
FUNCTION STUDIES 



■ Arterial Blood 
Gases 

•Spirometrv 

■ Diffusion Testing 
• Lung Volumes 




-FAST, ACCURATE 

RESULTS 
-QUALIFIED RESPIRATORY 

THERAPISTS 
L- PHYSICIAN SUPERVISED 



For more information call: (704) 332-8082 







669 



women graciously appeared for 7:00 a.m. caucus calls 
and held up throughout a steady pace of meetings and 
events. 

We are always treated to speakers of national stat- 
ure and this meeting was no exception. Senator Paula 
Hawkins of Florida lightheartedly told us what it is 
like to be one of two women in the Senate and the first 
with a husband. 

George Will, leading columnist and contributing 
editor for Newsweek, held our attention with his in- 
sightful comments regarding medicine for and in the 
economy. Commenting on a '"fundamental, glacial 
shift in American politics," he described the govern- 
ment as "the disease for which it pretends to be the 
cure." He believes that people now fear that we are 
killing the goose that laid the golden egg, and that 
"given the nature of the economy and current pres- 
sures on it from the public sector . . . there is a public 
understanding that we have passed a healthy point in 
making promises to ourselves through the public 
mechanisms of this welfare state." He says we are 
beginning to face great structural changes in America 
and mindboggling financial problems having to do 
with the "aging" of the country. And there will be 
continued painful adjustments of public promises. He 
pointed out that it's clear that the American people are 
most of all nervous about catastrophic illness — not 
basic things, and that they are increasingly mature 
about the difference between health and medicine. He 
said that our group forms a nucleus, as community 
leaders, of a revolution of public understanding about 
healthy living. Mr. Will also believes that given the 
current shifts and political realities, no man in national 
public life will make a serious attempt to add a national 
health program to the enormous structure that exists. 

"Stress is both friend and foe" according to Dr. 
Robert S. Eliot who entertained with personal wit and 
cartoons as he gave a serious message regarding man- 
aging 20th century stress. He believes that today's 
woman may be more stressed than man. His word for 
women, caught in a profusion of complicated role 
models, "It's OK to be what is OK with you." And, in 
handling stress, "can't fight, can't flee — flow." 

Reactions were widely varied to a symposium, 
"History of a Medical Marriage," presented by Dr. 
Gordon Deckert and his wife, Jane Chew Deckert, 
from the University of Oklahoma Department of 
Psychiatry. Fun included a grand performance of 
Peter Pan with Sandy Duncan. There was a smashing 
final curtain call when she was "flown" high out over 
the audience. 

Official auxiliary business will be reported in 
Facets. Mary Ellen Vaughn completed her presiden- 
tial year expressing the hope that we will continue to 
work in a "family spirit" and with the personal touch. 
A few 1981 highlights she noted are: increased usage 
of and 70 new entries in the Project Bank (bringing the 
total to 900 projects), more auxiliaries working in 
partnership with their medical societies; AMA-ERF 
raised $1,692,345.03 (nearly $90,000 more than last 
year); 15 states increased membership (but not North 



670 



CyCL«PEN-lV(cyclacillin) 

Indications 

Cytlacilhn hoi less in vitro achvily than other drugs in the ampicillin 
class and ils use should be confirtod fo these indications Treatment 
of the following infections: 
RESPIRATORY TRACT 

Tonsillitis and pharyngitis caused by Group A beto-hemol/tic 
streptococci 

Bronchitis and pneumonia caused byS pneumomoe (formerly 
D, pneuTionioe) 

Otitis media caused by S . pneumoniae (formerly D , 
pneumoniae) and H. inffuenzoe 

Acute exocerbotion of chronic bronchitis caused by H, in- 
fluenzae ' 

'Though clinical improvement has been shown, bocteriologic 
cures cannot be expected in oil potients with chronic respi- 
ratory disease due toH. influenzae: 
SKIN AND SKIN STRUCTURES (integumentary) infections caused 
by Group A beta-hemolytic streptococci and staphylococci, non- 
penicillinose producers 

URINARY TRACT INFECTIONS caused by f. col, and P. mirobi/is. 
(This drug should not be used in any£. co/i and P. mirabilis infec- 
tions other than urinary troct.) 

NOTE- Perform cultures and susceptibility tests initially and dur- 
ing treatment to monitor effectiveness of therapy and susceptibil- 
ity of bacteria. Therapy may be instituted prior to results of sen- 
sitivity testing 

Contraindications Controindicated in individuals with history of 
an allergic reoction to penicillins. 

Warnings Cyclacillin should only be prescribed for the indica- 
tions listed Herein. 

Cyclacillin has less in vitro activity than other drugs of the 
ampicillin class However, clinical trials demonstrated il is ef- 
ficacious for recommended indications 

Serious and occasional fatal hypersensitivity (anaphylactoid) 
reactions have been reporteci in patients on penicillin Al- 
though anaphylaxis is more frequent following parenteral 
use, it has occurred in patients on oral penicillins These reac- 
tions are more apt to occur in individuals with history of sen- 
sitivity to multiple allergens There are reports of patients 
with history of penicillin hypersensitivity reactions who ex- 
perienced severe hypersensitivity reactions when treated 
with a cephalosporin Before penicillin therapy, carefully in- 
quire about previous hypersensitivity reactions to penicillins, 
cephalosporins and other allergens. If allergic reoction oc- 
curs, discontinue drug and initiate appropriate theropy. Seri- 
ous anaphylactoid reactions require immediole emergency 
treatment with epinephrine Oxygen, I.V, steroids, airway 
management, including intubation, should also be adn^inis- 
tered as indicated- 
Precautions Prolonged use of antibiotics may promote over- 
growth of nonsuiceptible organisms. If superinfection occurs, lake 
appropriate measures, 

PREGNANCY, Pregnancy Category B. Reproduction studies per- 
formed in mice and rots at doses up fo 10 times the human dose 
revealed no evidence of impaired fertility or harm lo the fetus due 
to cyclacillin, There ore, however, no adequate and well- 
controlled studies in pregnant women. Because animal reproduc- 
tion studies are not always predictive of humon response, use this 
drug during pregnancy only if clearly needed. 
NURSING MOTHERS It is not known whether this drug is excreted 
in human milk Because many drugs ore. exercise caution when 
cyclacillin is given lo a nursing woman. 

Adverse Reactions Orol cyclacillin is generoMy well tolerated As 
with other penicillins, untoward sensitivity reactions are likely, 
particularly in those who previously demonstrated penicillin 
hypersensitivity or with history of allergy, asthma, hay fever, or 
urticorio Adverse reoctions reported with cyclacillin^ diarrhea (in 
approximately 1 out of 20 patients treated), nouseo and vomiting 
(m opproximolely 1 in 50), and skin rash (in approximately 1 in 
60) Isolated instances of headache, dizziness, abdominol pain, 
vaginitis, and urticaria have been reported, (See WARNINGS) 
Other less frequent adverse reactions which may occur and ore 
reported with other penicillins ore anemio. thrombocytopenia, 
thrombocytopenic purpura, leukopenio, neutropenia and 
eosmophilia. These reactions ore usually reversible on discontinu- 
ation of therapy. 

As with other semisynthetic penicillins, SGOT elevations hove been 
reported. 

As with antibiotic therapy generally, continue treatment at least 
48 to 72 hours after patient becomes asymptomatic or until bacte- 
rial eradication is evidenced. In Group A beta-hemolytic strep- 
tococcal infections, at least 10 days' treatment is recommended to 
guard against risk o' rheumatic fever or glomerulonephritis. In 
chronic urinary tract infection, frequent bocteriologic and clinical 
appraisal is necessory during therapy and possibly for several 
months after. Persistent infection may require treatment for sev- 
eral weeks 

Cyclocillin is not indicated in children under 2 months of oge. 
Patients with Rer>al Failure Cyclacillin may be safely administered 
to patients with reduced renal function. Due to prolonged serum 
holf-life, patients with various degrees of renal impairment may 
require change in dosage level (see DOSAGE AND ADMINISTRA- 
TION in package insert) 
Dosage (Give m equolly spaced doses) 



INFECTION 


ADULTS 




CHILDREN" 


RespirofOfy 

Tract 








Tonsillitis & 
Pharyngitis 


250 mg q 


,d. 


body weight < 20 kg 
(44 lbs) 125 mg q.i d 


Bronchitis and 






body weight > 20 kg 
(44 lbs) 250 mgq, id 


Pneumonic 








Mild or 
Moderate 


250 mgq. 


,d. 


50 mg/kg/day q.id. 


Infections 








Chronic 
Infections 


500 mgq. 


,d. 


100 mg/kg/day q, id 



O^tis Medio 250 mg to 500 mg 50 to 100 mg/kg/doyi 

q.i.d.T 

Skin & Skin 250 mg to 500 mg 50 to 100 mg/kg/doyt 

Structures q i,d,t 

Unnory Tract 500 mg q.id. 100 mg/kg/day 

'Dosage should not result in a dose higher than that for adults, 
tdepending on seventy 

Wyeth Laboratories 

' ' 1 Ptiiladeiphia, Pa 19101 



Lii' 



Half the dose 
is absorbed in 9 minutes! 

compared to 32 minutes for ampicillin* 







Mean blood levels in mcg/ml after 250 mg 
cyciacillin single oral dose 



7H 




1 2 3 4 5 

Time (hours after administration) 



Rapid, virtually complete absorption from Gl tract 
Exceptionally high peak blood levels - 3 times 
greater than ampicillin (Clinical efficacy may not 
always correlate with blood levels.) 
Rapidly excreted unchanged in urine — 
V/i times faster than ampicillin 



Fewer episodes of diarrhea and rash 
than with ampicillin in studies to date. 

Efficacy proven in the treatment 
of bronchitis, pneumonia, and upper 
respiratory infections.^ 

In 1 17 patients, 73 with bronchitis/pneumonia 
caused by S . pneumoniae and 44 with streptococcal 
sore throat caused by Group A beta-hemolytic 
streptococcus, CYCLAPEN'"-W achieved a clinical 
response rate of 100%! Bacterial eradication was 
95% and 86% respectively. 

tDue to susceptible organisms. 

See important information on facing page. 



posed on T V2 values for single oral doses of 500 mg cyciacillin 
woblet and 500 mg ampicillin copsule. Data on file, Wyeth Laboratories. 

lopyright© 1980, Wyeth Laboratories. All rights reserved. 



^Vyeth Laboratories ■ pnnadeiphia, pa 19101 

iA 



C/CUPEH-iV 

(I * 1 1 • \ 250 and 500 mg Tablets 

cyciacillin) -re°-- ^ 



more than just spectrum 



Carolina) and Resident Piiysician Spouses and Medi- 
cal Student Spouses (RPS/MSS) tripled to more than 
1,000 members. 

And last, but far from least, we have a new auxiliary 
president — Isobel Dvorsky. Those of you who saw 
her in Southern Pines in May recognized an excep- 
tional lady in every sense of the word. With grace and 
intelligence she will guide this organization she calls 
medicine's newest "specialist."" She feels the au- 
xiliary has the special ability to lead others in matters 



that relate to health, "because we have channels for 
getting information, finding out what needs to be done 
and helping to motivate others to act." We are chal- 
lenged by her interpretation of our organization as one 
with a "powerhouse potential,"' ready and waiting to 
be discovered by AMA, state and county medical 
societies. 

Isobel Dvorsky believes in the volunteer, and richly 
communicates her vision of a changed Auxiliary 
image and mission — she gives good reason for every 



\ 



* 



Physicians: we treat you 

seriously in the 

Air Force 



As an Air Force Medical Offi 
cer, you'll practice i 
sional environment 
ported by a team of h 
ly qualified technica 
assistants. You'l 
treat your patients 
in modern, well- 
equipped health care 
facilities. 

The Air Force Me 
Service will provid 
limited professional 
ment, with a care 
signed individual 
to complement yo 




skills and objectives. Air Force 
I Centers offer a full 
of opportunities in clini- 
edicine, including clini- 
cal investigation. 

Avoid the time con- 
suming burdens of pri- 
vate practice. Consider 

the benefits of Air Force 

medicine. Health care 

at its very best. 



USAF Health Professions Team 

1100 Navaho Drive 

Raleigh, North Carolina 27609 

Cair collect: (919) 755-4134 



R 



Air Force. A great way of life. 



i 



672 



Vol. 42. No. 9 



i 



doctor's wife continuing to give the auxiliary high 
priority. This was a first class meeting and if any of 
you can participate another year, I highly recommend 
you head for Chicago for the national AMA Auxiliary 
conclave. 

Eleanor Hunt (Mrs. O. Raymond) 

President Elect 

North Carolina Medical Society Auxiliary 



News Notes from the 

UNIVERSITY OF NORTH CAROLINA- 
CHAPEL HILL SCHOOL OF MEDICINE 
AND 
NORTH CAROLINA MEMORIAL HOSPITAL 



New nurseries for both healthy and sick infants, 
ultramodern labor and delivery rooms and attractive 
accommodations for new mothers were dedicated 
June 6 at North Carolina Memorial Hospital. 

Governor Jim Hunt was the main speaker at the 
dedication ceremony. 



N.C. Memorial Hospital is one of the state's 10 
regional referral centers for critically ill newborns and 
women with complicated pregnancies. 

The new facilities include a Neonatal Intensive Care 
Unit with special equipment for sick and premature 
newborns, an Intermediate Care Nursery for less 
critically ill infants, as well as a large Newborn Nur- 
sery for normal, healthy babies. 

The new Robert A. Ross Obstetrical Unit, named 
for the first chairman of obstetrics and gynecology 
here, will more than double the amount of space de- 
voted to obstetrical care. 



Better health care for the elderly in North Carolina 
and better understanding of the problems of old age 
are goals of a new Program on Aging established by 
the School of Medicine. 

Dr. Stuart Bondurant, dean of the School of 
Medicine, said the program will give focus to the in- 
stitution's "ongoing commitment to develop effective 
programs of teaching, research and health care in the 
field of aging." 

Bondurant announced the appointment of Dr. Paul 
Beck, professor of medicine, as director of the Pro- 
gram on Aging. Beck has served for the past year as 
director of the medical teaching service at the medical 




An apple a day worft 
keep alcoholism away! 

The alcoholic presents unique, baffling problems in 
medical practice. So does the person addicted or 
dependent on narcotics, tranquilizers, sedatives or 
stimulants. We specialize in acute care and long-term 
treatment of these conditions, offering a minimum 
28-day program. 

Do. you have a patient who needs this kind of help? 
You probably do because the illness is sneaky. For 
more information and guidelines on hov^ to identify 
^ajhese patients, write to us. 



*XjU*ta*»ajt^ ^^o^^aitaJL 



3]1 JONES MILL ROAD 
STATESBORO, GA. 30458 



(912)764-6236 



J.C.A.H. ACCREDITED 



September 1981, NCMJ 



673 



When painful spasm 
is the presenting 
symptom . . . 





^ i 



,.-> 





. . . in the functional bowel/irritable bowel 
syndrome* 

be sure to specify 




Berrtyr 

(dicyclomine 
hydrochioride USP) 

10 mg capsules, 20 mg tablets, 

10 mg/5 ml syrup, 10 mg/ml injection 



1f^pA.lAJrDcdf:^£^U^ CUrUni^C£e/b 



because: 

) The Bentyl molecule is a product of original Merrell research. 

^ At Merrell Dow, Bentyl must go through 140 checkpoints/tests from its synthesis 
through the packaging of the final product. 

^ Bentyl bioavailability of tablets, capsules, syrup and injectable is evidence of its 
prompt absorption. 

) Bentyl helps control abnormal gastrointestinal motor activity with minimal 

anticholinergic side effects. (See warnings, contraindications, Precautions, and Adverse Reactions on next page.) 

) The bioequivalence of the oral dosage forms permits a choice of tablet, capsules, 
or syrup that satisfies patient's dosage preferences. 

^ Significant pharmacologic effect in the distal colon compared to placebo,'' shows 
how Bentyl controls abnormal motor activity in the irritable colon patient.* 

This drug has been classified "probably" effective for this indication. 

Merrell Dow 

Reference: 

Chowdhury AR and Lorber SH: Personal communication. 1 980. (See Product Information on the next page before prescribing Bentyl.) 

although the dose of Bentyl used to show pharmacologic effect was 50 mg, which is a higher single dose than that permitted in the labeling, the dose was considered justified, 
ince the recommended daily dose of injectable Bentyl is 20 mg (2 ml) every 4 to 6 hours. Thus, in 8 hours, a patient could receive a total of 60 mg I.M. and. at that time, as a result 
'f the sustained plasma levels from the 20 mg injections at and 4 hours, might show an even higher plasma level than occurs after a single 50 mg dose, Presumably the same 
iharmacologic effect would follow. These observations do not constitute evidence of efficacy. 



Bentyl 



(dicyclomine hydrochloride USP) 

Capsules, Tablets, Syrup, Infection 
AVAILABLE ONLY ON PRESCRIPTION 
Brief Summary 



INDICATIONS 

Based on a review o( this drug by the National Academy o( 
Sciences-National Researcfi Council and/or other intormation, FDA 
fias classified the following mdicatiens as "probably" eftective 

For the treatment of tunctional bowel. irritable bowel syn- 
drome (irritable colon spastic colon, mucous colitis} and 
acute enterocolitis 

THESE FUNCTIONAL DISORDERS ARE OFTEN RELIEVED 
BY VARYING COMBINATIONS OF SEDATIVE REASSUR- 
ANCE, PHYSICIAN INTEREST, AMELIORATION OF EN- 
VIRONMENTAL FACTORS 
For use m the treatment ot infant colic (syrup). 

Final classification of the less-ihan-effective indications 
requires further investigation 



CONTRAINDICATIONS: Obstructive uropalhy (tor example, bladder 
neck obstruction due to prostatic hyperlrophy), oDstructive disease 
of the gastrointestinal tract (as m achalasia, pyloroduodenal 
stenosis), paralytic ileus, intestinal atony of the elderly or debili- 
tated patient, unstable cardiovascular status in acute hemorrhage, 
severe ulcerative colitis, toxic megacolon complicating ulcerative 
colitis, myasthenia gravis 

WARNINGS: In the presence of a high environmental temperature, 
heat prostration can occur with drug use (lever and heat stroke due 
to decreased sweating) Diarrhea may be an early symptom of 
incomplete intestinal obstruction, especially m patients with ileos- 
tomy or colostomy In this instance treatment with this drug would 
be inappropriate and possibly harmful Bentyl may produce drow- 
siness or blurred vision In this event, the patient should be warned 
not to engage in activities requiring mental alertness such as 
operating a motor vehicle or other machinery or perform hazardous 
work while taking this drug There are rare reports of infants, 6 
weeks of age and under, administered dicyclomine hydrochloride 
syrup, who have evidenced respiratory symptoms (breathing diffi- 
culty, shortness of breath, breathlessness, respiratory collapse, 
apnea), as well as seizures, syncope, asphyxia, pulse rate fluctua- 
tions, muscular hypotonia, and coma The above symptoms have 
occurred within minutes of ingestion and lasted 20 to 30 minutes 
The timing and nature of the reactions suggest that they were a 
consequence of local irritation and or aspiration rather than a direct 
pharmacologic effect No known deaths or permanent adverse 
effects have been reported Bentyl syrup should be used with 
caution m this age group 

PRECAUTIONS: Although studies have failed to demonstrate ad- 
verse effects ot dicyclomine hydrochloride in glaucoma or in 
patients with prostatic hypertrophy, it should be prescribed with 
caution in patients known to have or suspected of having glaucoma 
or prostatic hypertrophy 
Use with caution m patients with 
Autonomic neuropathy Hepatic or renal disease Ulcerative coli- 
tis Large doses may suppress intestinal motility to the point 
of producing a paralytic ileus and the use of this drug may 
precipitate or aggravate the serious complication of toxic 
megacolon 
Hyperthyroidism, coronary heart disease, congestive heart fail- 
ure, cardiac arrhythmias, and hypertension 
Hiatal hernia associated with reflux esophagitis since anti- 
cholinergic drugs may aggravate this condition 
Do not rely on the use ot the drug m the presence of complication of 
biliary tract disease investigate any tachycardia before giving 
anticholinergic (atropine-like) drugs since they may increase the 
heart rale With overdosage, a curare-like action may occur, 
ADVERSE REACTIONS: Anticholinergics antispasmodics produce 
certain effects which may be physiologic or toxic depending upon 
the individual patients response The physician must delineate 
these Adverse reactions may include xerostomia, urinary hesi- 
tancy and retention, blurred vision and tachycardia, palpitations, 
mydriasis, cycloplegia. increased ocular tension, loss of taste, 
headache, nervousness, drowsiness, weakness: dizziness, 
insomnia, nausea, vomiting, impotence, suppression of lactation, 
constipation, bloated feeling, severe allergic reaction or drug 
Idiosyncrasies including anaphylaxis, urticaria and other dermal 
manifestations, some degree of mental confusion andor excite- 
ment, especially in elderly persons, and decreased sweating With 
the iniectable form there may be a temporary sensation of light- 
headedness and occasionally local irritation 
DOSAGE AND ADMINISTRATION: Dosage must be adjusted to indi- 
vidual patient's needs. 
Usual Dosage 

Bentyl 10 mg capsule and syrup /Itfu/fs 1 or 2 capsufes or tea- 
spoonfuls syrup three or four times daily Children: 1 capsule or 
teaspoonful syrup three or four times daily. Infants '/? teaspoon- 
ful syrup three or tour times daily, (Dilute with equal volume 
of water } 
Bentyl 20 mg Adults 1 tablet three or four times daily. 
Bentyl Injection Adults 2 ml (20 mg.) every four to six hours 
intramuscularly only 
NOT FOR INTRAVENOUS USE. 
MANAGEMENT OF OVERDOSE: The signs and symptoms of over- 
dose are headache, nausea, vomiting, blurred vision, dilated 
pupils, hot. dry skin, dizziness, dryness of the mouth, difficulty in 
swallowing, CNS stimulation Treatment should consist of gastric 
lavage, emetics, and activated charcoal Barbiturates may be used 
either orally or intramuscularly for sedation but they should not be 
used if Bentyl with Phenobarbital has been ingested If indicated, 
parenteral cholinergic agents such as Urecholme^ (bethanecoi 
chloride USP) should be used 
Product Information as of July, 1980 
Injectable dosage forms manufactured by 
CONNAUGHT LABORATORIES, INC 
Swiftwater, Pennsylvania 18370 or 
TAYLOR PHARMACAL COMPANY 
Decatur, Illinois 62525 for 



Merrell 



M^^^ 



-7052 (y368Cl 



MERRELL DOW. PHARMACEUTICALS INC 

Subsidiary of The Dow Chemical Company 
Cincinnati. OH 4521 5 U S.A. 

MNO-7U 



school's Wake Area Health Education Center in Ra- 
leigh. 



One hundred and sixty new physicians were hon- 
ored May 17 at the School of Medicine's annual 
Hooding Ceremony. The class of 1981 includes 13 who 
completed M.D. degree requirements last December 
and one who finished last August. 

Some 619f of this year's medical graduates are 
entering training in primary care, including 31% in 
internal medicine, 12% in family medicine and 9% 
each in pediatrics and obstetrics and gynecology. 

More than two-thirds of those participating in the 
National Residency Matching Program were placed in 
the program of their first or second choice: 50% were 
matched with their first choice and 19% with their 
second. Approximately three-fourths were placed 
among their top three choices. 

Forty-seven new physicians are remaining in North 
Carolina for graduate training, 25 of whom will enter 
residencies at North Carolina Memorial Hosptial. 



Sixty-six students participated in the Medical Edu- 
cation Development (MED) Program offered by the 
schools of medicine and dentistry for students from 
disadvantaged backgrounds who have shown poten- 
tial for professional school. 

Now in its 14th year, the eight-week program simu- 
lates the experiences of beginning medical and dental 
students, according to Evelyn B. McCarthy, director. 
This year's participants included 58 students from 
North Carolina and eight from other states. Sixty of 
the students, are from ethnic minority groups, in- 
cluding 54 who are black. 

Thirty-one graduate institutions were represented, 
including 20 in North Carolina, 12 of the Consolidated 
University of North Carolina. 



The Hearing and Speech Center at North Carolina 
recently acquired a new computer which can map the 
path of nerve impulses from the ear to the brain, 
according to William G. Thomas, director of the cen- 
ter. 

The new machine, an auditory evoked response 
system, can be used to measure a patient's reaction to 
sound as nerve impulses travel through the auditory 
nerve to the brain. 

Data collected can be used to diagnose deafness, 
disease in the inner ear, failure of a stimulus to travel 
normally to the brain, or abnormal responses in the 
brain itself. It also can be used to determine differ- 
ences in processing between the right and left ear. 



With just one phone call, a doctor anywhere in 
North Carolina now can find out which of the state's 
newborn intensive care nurseries has room for the sick 
baby he needs to refer. 



Vol. 42. No. 9 



i 



A new computer-based communications network 
keeps personnel at 10 centers for sick and premature 
infants up-to-date on the availability of beds and spe- 
cial equipment at each of the other centers. So. if the 
first nursery a doctor calls is unable to take another 
baby, he can be referred immediately to the next 
closest nursery that has an empty bed. 

A computer housed in the School of Medicine con- 
trols the Neonatal Tele-communications Network. It 
is linked by telephone to computer terminals in each of 
the intensive care nurseries, so that information can 
be passed instantly from one nursery to another. 

Personnel in each nursery routinely feed into the 
network current information that referring doctors 
need to know, including: the availability of beds for 
both sick newborns and women with high-risk preg- 
nancies who may have sick babies, access to special 
medical equipment, whether transportation can be 
provided, and the and phone number of the person to 
call about referring patients. 

The network was developed by three UNC-CH 
medical scientists: biomedical engineers James Bos- 
tick and Dr. Henry Hsiao and pediatrician Dr. Edward 
Lawson. 

The network has been in operation since early 
March, and one hospital, Southeastern General Hos- 



pital in Lumberton, still has to be tied in. So far, 
Lawson said, the system seems to be working well. 
The 10 intensive care nurseries that currently make 
up the communication network are located at the fol- 
lowing hospitals: Memorial Mission Hospital, Ashe- 
ville: Charlotte Memorial Hospital, Charlotte; N.C. 
Baptist Hospital. Winston-Salem: Moses H. Cone 
Memorial Hospital, Greensboro: N.C. Memorial 
Hospital. Chapel Hill; Duke University Hospital, 
Durham: Wake County Medical Center. Raleigh 
Southeastern General Hospital. Lumberton; Pitt 
County Memorial Hospital. Greenville: and New 
Hanover Memorial Hospital. Wilmington. 



Medical students here honored a number of their 
teachers during the School of Medicine's annual 
awards and skits program in April. 

The faculty and housestaff winners and their awards 
were: Dr. W. Paul Biggers, The Professor Award; Dr. 
Lloyd R. Yonce, Medical Basic Science Teaching 
Award: Dr. James F. Donohue. Central Carolina 
Bank Excellence in Teaching Award: Dr. Stephen 
Ray Mitchell. Henry C. Fordham Award, and Dr. 
Lyle Spencer Saltzman. Outstanding Intern Award. 

Biggers, J. P. Riddle Distinguished Professor of 



^^^i^e^^^e^^m^. . . 



TEGA-CORT FORTE 1% 



TEGA - CORT - 0.5% 



(Available at all drug stores - Rx Only) 

SQUEEZE TYPE DISPENSER BOTTLES 

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Contraindications: Topical steroids have not been reported to have an adverse 
effect on pregnancy, the safety of their use in pregnant females has not absolutely 
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September 1981, NCMJ 



677 



Otolaryngology, was voted "Professor of the Year" 
by the senior class of the medical school. This award 
has been presented since 1950 by the graduating class 
to the faculty member "who by his willingness, under- 
standing and ability has contributed most to our medi- 
cal education." 

Diggers joined the medical school faculty in 1967. 
He is a 1959 graduate of Davidson College and earned 
his M.D. degree from UNC-CH in 1963. He isaformer 
winner of the CCB Excellence in Teaching Award. 

The Basic Science Teaching Award, presented to 
Yonce. associate professor of physiology, was estab- 
lished by the second-year class of 1965. It honors a 
faculty member from the basic medical sciences "who 
has contributed in a particularly effective way and 
devoted manner to their education." 

Yonce, whose teaching specialty is cardiovascular 
physiology, joined the faculty in 1957. He earned a 
B.S. degree in 1949 from Montana State University, 
and M.S. in 1952 from Oregon State University and a 
Ph.D. in 1955 from the University of Michigan. 

Donohue, last year's winner of The Professor 
Award, was selected by the entire student body to 
receive the CCB Excellence in Teaching Award this 
year. The award, which carries a stipend of $1,000, 
was established in 1973 by the Central Carolina Bank. 

He was appointed to the faculty in 1976 as an in- 



structor of medicine and has been an assistant profes- 
sor since 1977. A 1965 graduate of St. Peter's College 
in New Jersey, he received his M.D. degree in 1969 
from the New Jersey College of Medicine. 

The Henry C. Fordham and Outstanding Intern 
awards are given to members of the housestaff at 
North Carolina Memorial Hospital. 

The Fordham Award won by Mitchell, a resident in 
medicine, is given annually to a resident "in recogni- 
tion of his qualities of patience, humility and devotion 
to medicine as were possessed by Dr. Fordham." 
Henry Fordham was a brother of Dr. Christopher C. 
Fordham III, chancellor of the University. 

The Outstanding Intern Award, presented this year 
to Saltzman, an anesthesiology resident, is given by 
the second-year class to the intern they select as the 
most helpful to their class. 

Both Mitchell and Saltzman are graduates of the 
School of Medicine, earning their M.D. degrees in 
1976 and 1980. respectively. 



Presented each year to a resident in the Department 
of Surgery, this year the Nathan A. Womack award 
was shared by Dr. James W. Battaglini, chief resident 
in general surgery, and Dr. Ritchie P. Gillespie, chief 
resident in neurological surgery. The winners were 



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678 



Vol. 42, No. 9 



announced June 6 at the annual surgical residents' 
party. 

The award first given in 1969. was established by 
friends, associates and students of the late Dr. Nathan 
A. Womack. former Kenan professor and chairman of 
surgery. 

It is presented for general excellence in teaching, 
investigation and patient care to surgical residents in 
recognition of overall contributions to the residency 
program and the department of surgery. 



The School of Medicine has received $8,512.63 
from the American Medical Association Education 
and Research Foundation. 

The gift was presented during the annual meeting of 
the North Carolina Medical Society in May in Pine- 
hurst. The AMA Education and Research Founda- 
tion, which is supported by individual physicians, 
AMA Auxiliary members and others throughout the 
country, makes donations each year to the state's 
medical schools through the N.C. Medical Society. 

Dr. Stuart Bondurant, dean of the School of Medi- 
cien. said the money will be used for special educa- 
tional, research and operational needs of the medical 
school which are not otherwise funded. 

The check was presented by Mrs. C. L. Nance of 
Wilmington, AM A-ERF chairman for North Carolina. 
Dr. William B. Wood, director of continuing medical 
education here, accepted the contribution on behalf of 
the dean. 

Also participating in the presentation where Dr. 
M. Frank Sohmer Jr. of Winston-Salem and Mrs. Hal 
Rollins of Greensboro. 



The 13th annual scientific symposium of the Ameri- 
can Red Cross. May 14-15 in Washington. D.C., was 
held in honor of Dr. Kenneth M. Brinkhous. Alumni 
Distinguished Professor of Pathology Emeritus at the 
School of Medicine. 

The topic of the symposium was "Hemophilia and 
Hemostasis." 

Brinkhous has devoted nearly half a century to 
studies of blood clotting mechanisms and to methods 
of diagnosing and treating bleeding disorders. He is 
best known for his pioneering studies of blood coagu- 
lation that led to the first effective control of hemo- 
philia. 



Dr. Tai-Chan Peng, associate professor of phar- 
macology, was named president-elect of the Sigma Xi 
scientific research society at the annual banquet of the 
society's local chapter. 

Dr. R. MalcolmBrown Jr., professor of botany, was 
installed as president of the society for 1981-82. John 
B. Darling, zoology librarian, was elected to a two- 
year term as secretary. Dr. Frederick K. Pfaender, 
associate professor of environmental microbiology, is 
in the second year of his two-year term as treasurer. 

Dr. J. Logan Irvin, Kenan professor of biochemis- 
try and nutrition and 1980-81 president, gave the 
presidential address on "Chromatin Modifications 
During Spermatogenesis." 

Sigma Xi is a national organization dedicated to the 
encouragement of pure and applied research in vari- 
ous fields. Election to membership is considered a 
scientific distinction of high order and indicates 
achievement in research. 



Three appointments to the School of Medicine fac- 
ulty have been announced by Chancellor Christopher 
C. Fordham III. 

The new faculty members are: Dr. Jack D. McCue. 
associate professor of medicine and chief of the medi- 
cine teaching service at Moses Cone Memorial Hos- 
pital in Greensboro: Dr. Ali Shirkhoda. assistant pro- 
fessor of radiology: and Dr. Luigi Cubeddu. associate 
professor of pharmacology and medicine and chief of 
the division of clinical pharmacology. 



Five faculty members in the School of Medicine 
have been promoted to full professor. 

Chancellor Christopher C. Fordham III announced 
the promotions of Dr. W. Paul Biggers. Department of 
Surgery: Dr. Lorcan A. O'Tuama, Department of 
Neurology, Pediatrics and Medicine: Dr. Russell L. 
Pimmel. Departments of Medicine and Surgery: Dr. 
John B. Winfield. Department of Medicine: and Dr. 
William J. Yount. Department of Bacteriology and 
Immunology. The promotions were effective July 1. 

September 1981, NCMJ 



An anesthesiology library honoring Dr. Kenneth 
Sugioka. professor and chairman of the Department of 
Anesthesiology, was formally dedicated April 12 at 
ceremonies in the state dining room of the Morehead 
Planetarium. 

The library is funded by the donations from de- 
partmental alumni and current staff members and has 
been named The Kenneth Sugioka Library. More than 
250 people attended the dedication ceremonies with 
Dr. Stuart Bondurant. dean of School of Medicine, 
serving as guest speaker. 

Sugioka received his B.S. from the University of 
Denver and his M.D. from Washington University in 
1949. He came to the University of North Carolina at 
Chapel Hill in 1954 as an assistant professor of surgery 
(anesthesiology). 

He was named professor and chief of anesthesiol- 
ogy in 1964 and became chairman when anesthesiol- 
ogy was established as a separate department in 1969. 



Contributions making possible five endowed pro- 
fessorships were honored April 30 by the School of 
Medicine. 



679 



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They are Dr. M. D. "Rabbit" Bonner of Greens- 
boro. J. P. Riddle of Fayetteville, Dr. and Mrs. Sterl- 
ing A. Barrett of Waterloo, Iowa, and Dr. James A. 
Valone of Raleigh. The late Dr. H. Houston Merritt, 
former professor of neurology at Columbia Univer- 
sity, was honored posthumously. 

The benefactors' support of the School of Medicine 
was cited during the spring banquet of the Co- 
Founders Club, a donor organization. Earlier in the 
day. those currently holding the professorships spoke 
during the organization's spring meeting. 

The speakers included Dr. Thomas B. Barnett, 
Bonner Distinguished Professor of pulmonary and al- 
lied diseases; Dr. W. Paul Biggers. J. P. Riddle distin- 
guished Professor of otolaryngology: Dr. David E. 
Eifrig, the Dr. and Mrs. Sterling A. Barrett Distin- 
guished Professor of ophthalmology. Dr. James N. 
Hayward, the Dr. H. Houston Merritt Distinguished 
Professor of neurology: and Dr. Bradford Cannon, the 
first Dr. James A. Valone Distinguished Professor in 
plastic and reconstructive surgery. 

The day's activities also included the dedication of 
the H. Houston Merritt Electron Microscopy 
Laboratory in the Department of Neurology. 

Members of the Co-Founders Club each contribute 
at least $1 ,000 a year to the School of Medicine. The 
club meets in Chapel Hill each spring and fall. 



Larry R. Churchill, assistant professor of family 
medicine, attended a meeting of the Society for Health 
and Human Values on Ethical and Social Issues in 
Reproductive Biology March 26-28 at Eastern Vir- 
ginia Medical School in Norfolk. 



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News Notes from the — 

EAST CAROLINA UNIVERSITY 
SCHOOL OF MEDICINE 



The first physicians to complete residency training 
in internal medicine and pediatrics at the East Caro- 
lina University School of Medicine and Pitt County 
Memorial Hospital finished requirements for the post- 
graduate training programs in June. 

Four residents received specialty training in inter- 
nal medicine and two in pediatrics. The six physicians 
are remaining in North Carolina to practice or receive 
additional training. 

Five residents in family medicine and dentistry also 
completed postgraduate training in June. Last year the 
medical center honored four family physicians and 
two dentists, the first graduates of the medical cen- 
ter's seven residency programs. 

Completing training in internal medicine were Drs. 
Janice L. Strom of Louisville, Ky., Joseph Jan Creech 
of Kenly, George S. Hughes, Jr. of Norfolk, Va., and 
Nicholas A. Patrone of Chapel Hill. Strom will enter 

Vol. 42, No. 9 



practice with Dr. Mary Ellen Coulter in Windsor. 
Creech will be an emergency room physician at 
Johnston Memorial Hospital in Smithfield. 

Hughes will join the ECU faculty as assistant pro- 
fessor of medicine. Patrone will begin a fellowship in 
rheumatology at the University of North Carolina- 
Chapel Hill. 

The two pediatricians to complete training will both 
enter practice in Eastern North Carolina. Dr. Penny 
Miranda of Burgaw will return to Burgaw to practice. 
Dr. Jimmie Shuler of Orangeburg, S.C., will serve as a 
National Health Services Corps physician with Pem- 
broke and Dental Services in Pembroke. 

The family physicians who completed training in- 
cluded Drs. Janice Daugherty, Richard Rawl, James 
Nicholson and Charles McGaw. Daugherty. from 
Florham Park, N.J., will join the faculty at ECU's 
Family Practice Center, and Rawl, from Lexington, 
S.C., will serve as director of the Bethel Family Prac- 
tice Center, the medical school's satellite facility for 
primary care. 

Nicholson, from Wilmington, and McGaw, from 
Windsor, have established a family practice in Rober- 
sonville known as Robersonville Family Physicians. 



Dr. David Madow, a dental resident, will join a 
practice in Baltimore, Md. 



Dr. Walter J. Pories, professor and chairman of the 
Department of Surgery, has been elected president of 
the Society for Environmental Geo-chemistry and 
Health. 

The society, also known as the International Trace 
Element Society, has members in 24 countries who 
are involved in a broad spectrum of disciplines dealing 
with earth and biological sciences. 

Pories, a thoracic surgeon, has been actively in- 
volved in trace element research and coordinated the 
development of a trace element laboratory within the 
medical school. 

His primary research areas are zinc metabolism in 
wound healing and the development of radioisotope 
techniques for the study of body ion pools. 



An article by Dr. Jarlath M. MacKenna, assistant 
professor of obstetrics and gynecology. Dr. Ray 
Dombroski, fourth-year obstetrics and gynecology 
resident, and Dr. Robert G. Brame, professor and 
chairman of the Department of Obstetrics and 
Gynecology, appears in the June issue of the Ameri- 
can Journal of Obstetrics and Gynecology. The article 
is entitled "Comparison of Amniotic Fluid Lung 
Maturity Profiles in Paired Vaginal and Amniocen- 
tesis Specimens." 



Dr. Jo Ann Bell, director of Health Science Library, 
presented "A Library Administrator View of Certifi- 
cation" and "Marketing for Librarians" at the annual 
meeting of the Medical Library Association in Mon- 
treal. 



Dr. Jascha W. Danoff, a child psychiatrist, has been 
appointed professor of psychiatry. 

Prior to joining the School of Medicine, Danoff was 
associate professor of psychiatry at the Medical Col- 
lege of Georgia and a child psychiatry consultant at the 
Richmond County Mental Health Center in Augusta. 
He also was child psychiatrist at Gracewood School 
and Hospital, a regional retardation center in Augusta. 

He received his undergraduate degree from McGill 
University, Montreal, and his medical degree from 
Toronto University. He did postgraduate training at 
Mt. Sinai Hospital, Cleveland, and also at the Univer- 
sity of Toronto and MacMaster University in Toronto. 



Dr. Bernice C. McKibben has been appointed as- 
sociate director of the Health Science Library at the 
School of Medicine. 

She formerly was assistant professor of library sci- 
ence at the University of Oklahoma at Norman where 
she developed a biomedical librarianship program. 

McKibben received her doctoral degree from the 
University of Colorado in instructional technology 
and media. She received her master's degree in library 
science and bachelor's degree from the University of 
Denver. 



Dr. Judith Thomas, associate professor of surgery, 
division of surgical research, recently presented 
"Suppressor Cells in Rhesus Monkeys After Treat- 
ment with Anti-thymocyte Globulin: Regulation of 
Mitogen-induced Lymphocyte Proliferation" at the 
annual meeting of the American Society of Transplant 
Surgeons in Chicago. 



Dr. James L. Mathis, professor and chairman of the 
Department of Psychiatry, is the author of 
"Viewpoints: What Do Men Find Most Difficult to 
Understand About Women's Sexuality" appearing in 
the June issue of Medical Aspects of Human Sexual- 
ity. 



Dr. Charles E. Boklage, assistant professor of 
microbiology and immunology, recently presented 
"Twinning and Origins of Human Symmetry" at the 
Alumni Symposium for the Curriculum in Genetics at 
the UNC-CH School of Medicine. 



Dr. Leonard S. English, assistant professor of 
microbiology, attended the Seventh International 
Conference on Lymphatic Tissues and Germinal 
Centers in Immune Reactions June 15-19 in 
Groningen, Holland. English presented "Im- 
munoregulatory Factors Produced by Activated 
Lymph Nodes in vivo." 



September 1981, NCMJ 



681 



News Notes from the — 

BOWMAN GRAY SCHOOL 
OF MEDICINE 

WAKE FOREST UNIVERSITY 



When the Food and Drug Administration approves 
the use of a new class of drugs called calcium blockers, 
it will be partially as the result of work done at the 
Bowman Gray School of Medicine. 

Research done at the school for the past two years 
has produced evidence that calcium blockers are ef- 
fective. 

The work suggests that the most important initial 
use of calcium blockers will be in the chronic use by 
patients to avoid attacks of angina. 

But some physicians nationwide also foresee the 
day when calcium blockers may be used alone or in 
combination to treat high blood pressure. The drugs 
also may be used to reduce the damage being done by a 
heart attack as it occurs and may be given to patients 
at high risk of having a heart attack. 



Bowman Gray's research has found that calcium 
blockers are useful in treating patients with a spasm of 
the coronary artery. Such a spasm reduces the amount 
of blood and oxygen that the heart muscle receives. 
The result is chest pain. 

Calcium blockers help the coronary artery to relax. 
Blood flow to muscle increases and pain ceases. 
Medical center physicians report that some of the 
results of their studies have been dramatic. 



Much of the nation's research on the use of ul- 
trasound to diagnose hardening of the arteries in the 
neck and legs will occur over the next three years at 
the Bowman Gray School of Medicine. 

Of six grants recently awarded by the National 
Heart, Lung and Blood Institute (NHLBI) to support 
that research, two were awarded to Bowman Gray 
researchers. 

Together, the two grants total approximately $1 
million and will help determine whether pictures of 
arteries produced with ultrasound show the real ex- 
tent of existing atherosclerosis. 

One of the grants, involving a three-year study 



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682 



Vol. 42, No. 9 



of research animals, is the only one of its kind. Dr. 
M. Gene Bond, assistant professor of comparative 
medicine, is directing that project. 

The second grant is directed by Dr. James F. Toole, 
professor and chairman of the Department of Neurol- 
ogy. It is intended to evaluate equipment now being 
used on patients. 

While several ultrasound methods have been intro- 
duced over the past decade to screen patients, a study 
such as the one at Bowman Gray is needed to deter- 
mine which method is best. 

Results of the ultrasound studies will be compared 
with results obtained through angiography, an X-ray 
procedure currently regarded as the surest diagnostic 
tool for detecting atherosclerosis in the neck and legs. 

The results of both Toole's and Bond's research will 
be sent to the Research Triangle Institute, which has 
been awarded a grant to evaluate the information pro- 
duced by the six projects supported through NHLBI 
funding. 

Bond's work is designed to evaluate the accuracy 
and limitations of more advanced ultrasound equip- 
ment. He and his colleagues will work on monkeys in 
studying the inside surfaces of the artery and the 
thickness of the wall. 

They hope to be able to detect very early stages of 
atherosclerosis and to track the disease's progress 
using very powerful instrumentation. 



Dr. A. Ronald Cowley, who completed his graduate 
training in radiology at Bowman Gray this past sum- 
mer, has been honored by the school's Department of 
Radiology. 

He was given the Radiology Faculty Award, which 
is presented each year by the faculty members in the 
department to the resident who demonstrated 
superior scholarship and potential as a diagnostic 
radiologist. 

Earlier this year Cowley received the Cornelius G. 
Dyke Memorial Award, the nation's most prestigious 
award which can be given to a young neuroradiologist. 



Dr. Joseph G. Gordon, who was appointed to the 
Bowman Gray faculty in 1973, has been honored for 
teaching excellence by the school's Department of 
Radiology. 

He was presented with the James L. Quinn III Me- 
morial Award for teaching excellence. Radiology res- 
idents present the award each year to a faculty mem- 
ber in the department. 

The award was established in memory of Dr. Quinn, 
a Bowman Gray alumnus and former faculty member 
who was a nationally-known nuclear medicine spe- 
cialist. Quinn died of cancer in 1980. 



Dr. Laurence A. Bradley, assistant professor of 
psychology at Bowman Gray, is the co-editor of anew 
textbook on medical psychology. 

September 1981, NCMJ 



The book, "Medical Psychology — Contributions 
to Behavioral Medicine," contains chapters written 
by 39 contributing authors. The book covers assess- 
ment, treatment and prevention of medical problems 
such as hypertension, chronic pain, obesity and 
cancer. 

Bradley's co-editor is Dr. Charles K. Prokop at the 
Texas Tech University Health Sciences Center. 

The book will be used as a textbook for medical 
students at Bowman Gray and at other schools 
nationwide. 

Bradley is interim director of Bowman Gray's Sec- 
tion on Medical Psychology and directs a clinic for 
patients with chronic low back pain. 



Dr. Henry S. Miller Jr., professor of medicine at 
Bowman Gray, has been installed as president of the 
American College of Sports Medicine. 

The organization, with 7,500 members from the 
U.S. and Canada, was begun in the 1960s by people 
involved in physical education and the physiology of 
exercise. Today, the organization's scope has in- 
creased to involve the medical aspects of sports. 

The college is concerned with the role of exercise in 
cardiac and respiratory rehabilitation, with the per- 
formance and injuries sustained by athletes and with 
research into muscle development and changes con- 
nected with physical activity. 



A scholarship fund has been established at Bowman 
Gray in memory of Dr. Norman M. Sulkin, former 
professor and chairman of the school's Department of 
Anatomy. 

The fund was established through memorial gifts 
from Dr. Sulkin's family, colleagues and friends. 

Starting in the fall of 1982, the fund will provide 
scholarship aid to a student in neuroanatomy, pursu- 
ing the Ph.D. degree through the Biomedical Graduate 
Studies Program at the medical school. 

Dr. Sulkin, who died in 1975, was a member of the 
Bowman Gray faculty for 23 years and was chairman 
of the Department of Anatomy for 16 years. He was 
named the William Neal Reynolds Professor of 
Anatomy in 1961. 

He was known internationally for his work in 
neuroanatomy and the neurobiology of aging. 



Michael Merriman, transplant coordinator for the 
Bowman Gray/Baptist Hospital Medical Center, has 
been elected treasurer of the North American Trans- 
plant Coordinators Organization. 

Merriman. who joined the medical center in 1976 as 
transplant coordinator, previously has served as the 
organization's chairman and co-chairman of the 
legal/ethical issues committee. 



Dr. Richard C. Proctor, professor and chairman of 

683 



Bowman Gray's Department of Psychiatry, has been 
appointed chairman of the committee to work with the 
North Carolina Industrial Commission by the North 
Carolina Medical Society. 



Dr. Charles H. Duckett, associate professor of fam- 
ily and community medicine, has been appointed to 
the Credentials Committee of the North Carolina 
Medical Society. 



Dr. Walter Bo. professor of anatomy, has been 
elected to a four-year term as a councillor of the Soci- 
ety for Experimental Biology and Medicine. 



Dr. Joseph E. Johnson III. professor and chairman 
of the Department of Medicine, has been elected 
president-elect of the Association of Professors of 
Medicine. It is composed of chairmen of the depart- 
ments of medicine in all American medical schools. 



Dr. George Rovere, associate professor of or- 
thopedic surgery, has been re-elected to the Continu- 
ing Education Committee of the American Orthopedic 
Society for Sports Medicine 



Dr. Vernon Jobson. assistant professor of obstet- 
rics and gynecology, has been selected as a member of 
the American Medical Association's Physician Re- 
search and Evaluation Panel. 



I 



684 



Vol. 42, No. 9 I, 



J 



Bactrim 

(trimethoprim and sulfamethoxazole) ■ 

succeeds 



gjjj^l^r Expanding _ 

3 susceptible l^^*^ LlovJlLllIlt^oo ill 

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September 



Before prescribing, please consult complete product information, a summary of 
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Initial episodes of uncomplicated urinary tract infections be treated with a single 
effective antibacterial agent rather than the combination. Note The increasing 
frequency of resistant organisms limits the usefulness ot all antibactenals, especially in 
these urinary tract infeclions. 

For acute otitis media in children due to susceptible strains of Haemophilus 
Influenzae or Sfrepfococcus pneumoniae when in physician's judgment it offers an 
advantage over other antimicrobials. Limited clinical information presently 
available on effectiveness of treatment of otitis media with Bactrim when infection 
is due to ampiciliin-resistant Haemophilus Influenzae. To date, there are limited 
data on the safety of repeated use of Bactrim in children under two years of age. 
Bactrim is not indicated for prophylactic or prolonged administration in otitis 
media at any age. 

For acute exacerbations of chronic bronchitis in adults due to susceptible strains 
of Haemophilus influenzae or Streptococcus pneumoniae when in physicians 
judgment it offers an advantage over a single antimicrobial agent. 
For enteritis due to susceptible strains of Shigella flexneri and Shigella sonnei 
when antibacterial therapy is indicated. 

Also for the treatment of documented Pneumocystis carinii pneumonitis. To date, 
this drug has been tested only in patients 9 months to 16 years of age who were 
Immunosuppressed by cancer therapy. 

Contraindications: Hypersensitivity to trimethoprim or sulfonamides; patients with 
documenied megaloblastic anemia due to folate deficiency; pregnancy at term; 
nursing mothers because sulfonamides are excreted in human milk and may cause 
kernicterus infants less than 2 months of age 

Warnings: BACTRIM SHOULD NOT BE USED TO TREAT STREPTOCOCCAL 
PHARYNGITIS. Clinical studies show that patients with group A /3-hemolytic 
streptococcal tonsillopharyngitis have higher incidence of bactenotogic failure when 
treated with Bactrim than do those treated with penicillin. Deaths from hypersensitivity 
reactions, agranulocytosis, aplastic anemia and other blood dyscrasias have been 
associated with sulfonamides. Experience with trimethoprim is much more limited but 
occasional interference with hematopoiesis has been reported as well as an increased 
incidence of thrombopenia with purpura in elderly patients on certain diuretics, 
primarily thiazides. Sore throat, fever, pallor, purpura or jaundice may be early signs of 
serious blood disorders. Frequent CBC's are recommended; therapy should be 
discontinued if a significantly reduced count of any formed blood element is noted. 
Precautions: General. Use cautiously in patients with 
impaired renal or hepatic function, possible folate 
deficiency, severe allergy or bronchial asthma In 
patients with glucose-6-phosphate dehydrogenase 
deficiency, hemolysis, frequently dose-related, may 
occur. During therapy, maintain adequate fluid intake and 
perform frequent urinalyses, with careful microscopic 
examination, and renal function tests, particularly where 
there is impaired renal function. Bactrim may prolong 
prothrombin time in those receiving warfarin; reassess 
coagulation time when administering Bactrim to these 
patients. 

Pregnancy Teratogenic Effects: Pregnancy Category C. 
Because trimethoprim and sulfamethoxazole may inter- 
fere with folic acid metabolism, use during pregnancy 
only if potential benefits justify the potential risk to the 
fetus 

Adverse Reactions: All major reactions to sulfonamides 
and trimethoprim are included, even if not reported with 
Bactrim Blood dyscrasias Agranulocytosis, aplastic 
anemia, megaloblastic anemia, thrombopenia, leuko- 
penia, hemolytic anemia, purpura, hypoprothrombinemia 
and methemoglobinemia Allergic reactions: Erythema 
multiforme, Stevens-Johnson syndrome, generalized skin eruptions, epidermal 
necrolysis, urticaria, serum sickness, pruritus, exfoliative dermatitis, anaphylactoid 
reactions, periorbital edema, conjunctival and scleral injection, photosensitization, 
arthralgia and allergic myocarditis. Gastrointestinal reactions Glossitis, stomatitis, 
nausea, emesis, abdominal pains, hepatitis, diarrhea and pancreatitis. CNS reactions: 
Headache, peripheral neuritis, mental depression, convulsions, ataxia, hallucinations, 
tinnitus, vertigo, insomnia, apathy, tatigue, muscle weakness and nervousness. 
Miscellaneous reactions Drug fever, chills, toxic nephrosis with oliguria and anuria, 
periarteritis nodosa and L E phenomenon Due to certain chemical similarities to some 
goitrogens, diuretics (acetazolamide, thiazides) and oral hypoglycemic agents, 
sulfonamides have caused rare instances of goiter production, diuresis and 
hypoglycemia in patients, cross-sensitivity with these agents may exist. In rats, long- 
term therapy with sulfonamides has produced thyroid malignancies. 
Dosage: Not recommended for infants less than two months of age. 
URINARY TRACT INFECTIONS AND SHIGELLOSIS IN ADULTS AND CHILDREN. AND 
ACUTE OTITIS MEDIA IN CHILDREN: 

Adults: Usual adult dosage for urinary tract infections— 1 DS tablet (double strength). 
2 tablets (single strength) or 4 teasp. (20 ml) b.i.d. for 10-14 days. Use identical daily 
dosage tor 5 days for shigellosis. 

Children Recommended dosage for children with urinary tract infections or acute otitis 
media— 8 mg/kg trimethoprim and 40 mg/kg sulfamethoxazole per 24 hours, in two 
divided doses tor 10 days. Use identical daily dosage for 5 days for shigellosis. 
For patients with renal impairment Use recommended dosage regimen when creatinine 
clearance is above 30 ml/min. If creatinine clearance is between 15 and 30 ml/min, 
use one-half the usual regimen, Bactrim is not recommended if creatinine clearance is 
below 15 ml/mm 

ACUTE EXACERBATIONS OF CHRONIC BRONCHITIS IN ADULTS: 
Usual adult dosage. 1 DS tablet (double strength), 2 tablets (single strength) or 
4 teasp (20 ml) bid. for 14 days. 
PNEUMOCYSTIS CARINII PNEUMONITIS: 

Recommended dosage 20 mg/kg trimethoprim and 100 mg/kg sulfamethoxazole per 
24 hours in equal doses every 6 hours for 14 days. See complete product information 
for suggested children's dosage table. 

Supplied: Double Strength (DS) tablets, each containing 160 mg trimethoprim and 800 
mg sulfamethoxazole, bottles of 100, Tel-E-Dose® packages of 100; Prescription Paks 
of 20 and 28. Tablets, each containing 80 mg trimethoprim and 400 mg sulfamethox- 
azole— bottles of 100 and 500, Tel-E-Dose® packages of 100, Prescription Paks of 40. 
Pediatric Suspension, containing 40 mg trimethoprim and 200 mg sulfamethoxazole 
per teaspoonful (5 ml); cherry-flavored— bottles of 100 ml and 16 oz (1 pint). 
Suspension, containing 40 mg trimethoprim and 200 mg sulfamethoxazole per 
teaspoonful (5 ml); fruii-licorice flavored — bottles of 16 oz (1 pint). 



ROCHE LABORATORIES 
ROCHE y Division of Hoffmann-La Roche Inc. 
/@ Nutley, New Jersey 07110 



in shigellosis... 

faster relief of 
diarrhea than with 
ampicillin^ 




*^ 






from site to source 

Bactrim continues to demonstrate high clinical effec- 
tiveness in recurrent urinary tract infections. Bactrim 
reaches effective levels in urine, serum, and renal 
tissue' . . .the trimethoprim component diffuses into 
vaginal secretions in bactericidal concentrations'... 
and in the fecal flora, Bactrim effectively suppresses 
Enterobacteriaceae'^ with little resulting emergence 
of resistant organisms. 

1. Rubin RH, Swartz MN: N EnglJ Med 303 A26-A3Z. Aug 21. 1980-2. Data on lile. 
Medical Department. Hoffmann-La Roche Inc. 



Bactrim DS 

160 mg trimethoprim and 800 mg s ulfamethoxazole 
DOUBLE STRENGTH TABLETS 



OCT 



51 



Htxati 



SG'ilHClS 



i\m^H 



maximizes results with B.I.D. eom enience 



•due to susceptible strains of indicated organisms 



Please see previous page for summary of product information. 



Carolina 



MEDICAL JOURNAL 



The Official Journal of the NORTH CAROLINA MEDICAL SOCIETY D D D October 1981, Vol. 42, 


No. 10 


Original Articles 




Editorials 




The New Tertiary Obstetrical Center: 
1 More Than Men and Machines . . 


705 


Report From West Germany 


725 


1 R.G.Brame,M.D., J.MacKenna, 




Medicine, Competition, The Federal 




1 M.D., and D. E. D. Jones, M.D. 




Trade Commission and the Post 








Office 


726 


1 Miliary Tuberculosis, With Adult Re- 








spiratory Distress Syndrome and a 








Leukemoid Reaction 


709 


Bulletin Board 




Douglas Jay Sprung, M.D. 




New Members of the State Society 


735 


Peroneal Palsy in Patients With De- 
mentia 


711 


What? When? Where? 


736 


E. Wayne Massey, M.D. 




Auxiliary to the North Carolina 








Medical Society 


737 


Current Therapy 




News Notes from the East Carolina 




Thvroid Nodules- 1981 


713 


University School of Medicine . . 


741 


Warner M. Burch, Jr., M.D. 




News Notes from the University of 
North Carolina-Chapel Hill 
School of Medicine and North 




Special Article 




Carolina Memorial Hospital 


742 


Dedicatory Address — Duke Uni- 




News Notes from tl^^owman Gjisy 


■-■ 


versity Hospital, North Division . 


715 


School of Medic^ of Wake ^ 




Steven MuUer, Ph.D. 




Forest Universil^ §§. . 

News Notes from^ Du@ Ung^r- 


745 


Mini-Feature 




sity Medical C^pr . . ^. . .^i. . 


747 


Toxic Encounters of the Dangerous 




Classified Ads . .'^. ....*!. . .§-. . . 

Index to Adverti^ . . .^. . . fS^ . . . 


749 


Kind — Tricyclic Antidepressant 




750 


Overdose 


724 






Ronald B. Mack, M.D. 




f 1 




..,-nn KOOMEN 


MD 








2760T 


1982 Mid-Winter Conference: Feb. . 


5-6, 


Ra,UF!GH. N. C. 




Winston-Salem 
1982 Annual Sessions: May 6-9, 
Pinehurst 




i _^ 








1 




.^ 





FOR THE 7 OF 10 NONPSYCHOTK: 





Clear correlation between anxiety and depression^ 



The above graph illustrates a relationship between anxiety and depression, indicating that patients seldom 
present with anxiety or depression alone, more often they have both in varying degrees. Data based on a 
sampling ot 100 outpatients (64 male, 36 temole) seen at a general psychiatric clinic. 
'Adapted trom Claghom, J, The anxiety-depression syndrome. Psychosomalics ;;:438-441, Sept-Oct 1970. 



Anxiefy Scores 
10 20 30 40 




DEPRESSED PATIENTS WHO ARE 

ALSO ANXIOUS''^ 



Most depressed patients are also anxious. , . 

Some authors estimate that 70% ot all nonpsychotic patients with symptoms of 
depression hove concomitant symptoms ot anxiety'^ One author found a distinct 
correlation between anxiety and depression scores in 100 nonpsychotic outpatients 
administered the Minnesota Multiphasic Personality Inventory in o general psychiatric 
clinic.^ As depression scores increased, so did anxiety scores. No attempt was made 
to select patients other than to exclude psychotics. 



Anxiety Scores 



- 



50 



but not psychotic 



The logic ot treating both components of anxious depression is clear Antipsychotics, 
like the phenothiazines, however, carry a well-documented nsk of tardive dyskinesia." 
Because of this, an AFW Task Force recently recommended the judicious use ot pheno- 
thiazines in coses other than chronic psychosis or the use of alternative treatments. 



A better way to give relief 



Limbitrol combines the specific anxiolytic action of Librium" (chlordiazepoxide 
HCI/Roche) — a benzodiazepine with a long history of safe use — with the 
antidepressant action of amithptyline, a thcyclic ot established clinical efficacy In 
compahson to phenothiazines, Limbitrol and its components have rarely been 
associated with tardive dyskinesia or other extrapyramidal side effects. And in terms 
of rapid response and patient compliance, Limbitrol appears to be superior to 
amithptyline alone. Controlled multiclinic studies showed Limbitrol relieved more 
symptoms more rapidly than did amithptyline.^ Despite a higher incidence of 
drowsiness, the dropout rate due to side effects vras lower with Limbitrol. (See 
adverse reactions section in summary of product information on next page. As 
with any CNS-acting agent, patients should be cautioned about driving or using 
dangerous machines while on therapy with Limbitrol.) 

References: 1. Rickels K; Drug treatment of anxiety, in Psychopharmacology in the Practice of Medicine, 
ed, Jarvik ME. New York, Appleton-Century-Crofts, 1977, p. 316 2. Schatzberg AR Cole JO Benzodiaze- 
pines in depressive disorders. Arcli Gen Psychiatry 35 1359-1365, 1978 3. Claghorn J Ttie anxiety- 
depression syndrome. Psychosomatics /?.438-441, 1970. 4. The Task Force on Late Neurological Effects 
of Antipsychotic Drugs; Tardive dyskinesia, summary of a task force report of the American Psychiotric 
Association. Am J Psychiatry /37: 11 63-1 172, 1980. 5. Feighner JP etal- A placebo-controlled multi- 
center trio! ot Limbitrol versus itscomponents (amitriptyline and chlordiazepoxide) in the symptomatic 
treatment of depressive illness. Psychopharmacology 61. 2^7 -225. 1979. 



In moderate depression and anxiety 

Limbitrol 

Tablets 5-12.5 each containing 5 mg chlordiazepoxide and 12.5 mg amitriptyline 

(as the hydrochloride salt) 
tablets 10-25 each containing 10 mg chlordiazepoxide and 25 mg amitriptyline 

(as the hydrochlonde salt) 

Relief wittiout a phenottiiazine 

Pleose see summory of product Information on next page. 



<R 



LIMBITROL ' TABLETS Tranquilizer-Antidepressant 

Before prescribing, please consult complete product Information, 
a summory of which follows: 

Indications: Relief o( moderate to severe depression associoted with moderate 
to severe anxiety 

Controlndlcdtlons: Known tiypersensitivity to benzodiazepines or tricyclic 
antidepressants Do not use wilti monoamine oxidase (MAO) inhibitors or 
within 14 days tallowing discontinuation of t^lAO inhibitors since hyperpyretic 
crises, severe convulsions and deaths hdve occurred with concomitant use, 
then intlidte cautiously, gradually increasing dosage until optimal response is 
achieved Contramdicated during acute recovery phase following myocardial 
infarction 

Warnings: Use with great care in patients with history of urinary retention or 
angle-closure glaucoma Severe constipation may occur in patients taking 
tricyclic antidepressants and anticholmergic-type drugs Closely supervise 
cardiovascular patients (Arrhythmias, sinus tachycardid dnd prolongation of 
conduction time reported with use of tricyclic antidepressants, especially high 
doses t^flyocardial infarction and stroke reported with use of this class of 
drugs ) Caution patients about possible combined effects with alcohol and 
other CNS depressants dnd against hazardous occupations requiring complete 
mental alertness (e g , operating machinery driving) 

Usage In Pregnancy: Use of minor tranquilizers during the first 
trimester should almost always be avoided because of Increased 
risk of congenital malformations as suggested In several studies. 
Consider possibility of pregnancy when Instituting therapy; advise 
patients to discuss therapy If they Intend to or do become pregnant. 
Since physical and psychological dependence to chlordiazepoxide have been 
reported rarely use caution m administering Limbitrol to oddicfion-prone 
individuals or those who might increase dosage, withdrawal symptoms 
following discontinuation of either component alone hove been reported 
(ndused, headache and malaise lor omitripfylme, symptoms [including 
convulsions] similar lo those of barbiturate withdrawal for chlordiazepoxide) 
Precautions: Use with cdution in patients with a history of seizures, in 
hyperthyroid patients or those on thyroid medication, and in patients with 
impaired renal or hepatic function Because of the possibility of suicide in 
depressed pdfients, do not permit easy access to large quantities in these 
patients Periodic liver function tests and blood counts are recommended 
during prolonged treofment Amilripfyline component may block action of 
guanethidine or similar antihypertensives Concomitant use with other 
psychotropic drugs has not been evaluated sedative effects may be additive 
Discontinue several days before surgery Limit concomitant administration of 
ECT to essential treatment See Warnings for precautions about pregnancy 
Limbitrol should not be taken during the nursing period Not recommended 
n children under 12 

In the elderly and debilitdted, limit lo smallest effective dosage to preclude 
ataxia, oversedation, contusion or anticholinergic effects 
Adverse Reactions: f^ast frequently reported ore those ossocioled with either 
component alone drowsiness, dry mouth, constipation, blurred vision, 
dizziness and bloating Less frequently occurring reactions include vivid 
dredms, impotence, tremor, confusion and ndsdl congestion Ivlony depressive 
symptoms including anorexia, fatigue, weakness, restlessness and lethargy 
hove been reported ds side effects of both Limbitrol and amitriptylme 
Granulocytopenia, jaundice and hepatic dysfunction hove been observed 
rorely 

The following list includes ddverse reactions not reported with Limbitrol but 
requiring consideration because they hove been reported with one or both 
components or closely related drugs 

Cardiovascular Hypotension, hypertension, tachycardia, palpitations, myo- 
cardidl infdrction, arrhythmias, heart block, stroke 
Psyctnalnc Euphoria, apprehension, poor concentration, delusions, halluci- 
nations, hypomonia and increased or decreased libido 
Neurologic Incoordindtion, otoxid, numbness, tingling dnd paresthesias of the 
extremities, extrapyramiddl symptoms, syncope, chonges in EEG patterns 
Anticholinergic Disturbance of occommoddtio.i, pdralytic ileus, urinary 
retention, dilatation of urinary tract 

Allergic Skin rash, uflicoria, photosensifization, edema of foce and tongue, 
pruritus 

Hematologic Bone marrow depression including agranulocytosis, 
eosinophilio, purpura, fhrombacytopenia 

Gastrointestinal Nausea, epigastric distress, vomiting, anorexia, stomatitis, 
peculiar taste, diarrhea, black tongue 

Enaocnne Testicular swelling and gynecomastia in the mole, breast 
enlorgemenL galactorrhea and minor menstrual irregularities in the female 
and elevation ond lowering of blood sugar levels 
Other Headache, weight gam or loss, increased perspiration, urinary 
frequency, mydriasis, joundice, alopecia, parotid swelling 
Overdosage: Immediately hospitalize patient suspected of hoving Inken on 
overdose Treatment is symptomatic and supportive I V administrdtion of 1 to 
3 mg physostigmine salicylate has been reported to reverse the symptoms of 
amitriptylme poisoning See complete product information for monifeslotion 
and treatment 

Dosage: individualize dccordmg to symptom severity and patient response 
Reduce to smallest effective dosage when satisfactory response is obtained 
Ldrger portion of doily dose moy be token at bedtime Single h s dose may 
suffice for some patients Lower dosages ore recommended for the elderly 
Limbitrol 10-25, initial dosage of three to four toblels doily in divided doses, 
ncreosed to six tablets or decredsed to two Idblets doily os required Limbitrol 
5-12 5, mitiol dosage of three to four tablets daily in divided doses, for 
patients who do not tolerate higher doses 

How Supplied: White, film-coated tablets, each contoining 10 mg chlor- 
diazepoxide ond 25 mg amitriptylme (as the hydrochloride salt) and blue, 
film-codted fdblets, eoch containing 5 mg chlordidzepoxide and 12 5 mg 
amitriptylme (as the hydrochloride soil)— bottles of 100 and 600, Tel-E-Dose' 
packages of 100, available in troys of 4 reverse-numbered boxes of 25, 
and in boxes containing 10 strips of 10, Prescription Poks of 50 



NORTH CAROLINA 
MEDICAL SOCIETY 
MEETINGS 




UU 
AHEM 



MID-WINTER CONFERENCI 

February 5-6, 1982 

Winston-Salem, N.C. 



ANNUAL MEETING 

May 6-9, 1982 

Pinehurst Hotel 
Pinehurst, N.C. 



<S> 



ROCHE PRODUCTS INC 
tvlonofi, Puerto Rico 00701 



October1981, Vol. 42, No. 10 



NORTH CAROLINA MEDICAL JOURNAL 

Published Monthly as the Official Organ of The North Carolina Medical Society (issN-0029-2559) 



STAFF 

John H. Felts, M.D. 
Winston-Salem 

EDITOR 

William N. Hilliard 
Raleigh 

BUSINESS MANAGER 

April A. Hart 

MANAGING EDITOR 



EDITORIAL BOARD 

Charles W. Styron, M.D. 
Raleigh 

CHAIRMAN 

George Johnson, Jr., M.D. 
Chapel Hill 

Edwin W. Monroe, M.D. 
Greenville 

Robert W. Prichard, M.D. 
Winston-Salem 

Rose Pully, M.D. 
Kinston 

Louis Shaffner, M.D. 
Winston-Salem 

Jay Arena, M.D. 
Durham 

Jack Hughes. M.D. 
Durham 



The appearance of an advertisement in this publication does not 
constitute any endorsement of the subject or claims of the 
advertisements. 

The Society is not to be considered as endorsing the views and 
opinions advanced by authors of papers delivered at the Annual 
Meeting or published in the official publication of the Society. 
— Constitution and Bylaws of the North Carolina Medical 
Society. Chapter IV, Section 4, page 4. 

NORTH CAROLINA MEDICAL JOURNAL, 300 S. Haw- 
thorne Rd., Winston-Salem, N.C. 27103, is owned and pub- 
lished by The North Carolina Medical Society under the direc- 
tion of its Editorial Board. Copyright® The North Carolina 
Medical Society 1981. Address manuscripts and communica- 
tions regarding editorial matter to this Winston-Salem address. 
Questions relating to subscription rates, advertising, etc., 
should be addressed to the Business Manager, Box 27167, 
Raleigh, N.C. 27611. All advertisements are accepted subject 
to the approval of a screening committee of the State Medical 
Journal Advertising Bureau, 711 South Blvd., Oak Park, 
Illinois 60302 and/or by a Committee of the Editorial Board of 
the North Carolina Medical Journal in respect to strictly local 
advertising. Instructions to authors appear in the January and 
July issues. Annual Subscription, $12.00. Single copies, $2.00. 
Publication office: Edwards & Broughton Co., P.O. Box 27286, 
Raleigh, N.C. 27611. Second-class postage paid at Raleigh, 
North Carolina 276U. 






Winchester Surgical Supply Company 

200 South TorrenceSt. Charlotte, N.C. 28204 
Phone No. 704-372-2240 
MEDICAL SUPPLY DIVISION FOR YOUR PATIENTS AT HOME 
1500 E. THIRD STREET Phone No. 704/332-1217 

Winchester-Ritch Surgical Company 

421 West Smith St. Greensboro, N.C. 27401 
Phone No. 919-273-5581 

Serving the MEDICAL PROFESSION of NORTH CAROUNA 
and SOUTH CAROUNA tince 1919. 

We equip many new Doctors beginning practice each year, and invite your inquiries. 

Our salesmen are located in all parts of North Carolina 

We have DISPLAYED at every N.C. State Medical Society Meeting since 1921, and advertised 
CONTINUOUSLY in the N.C. Journal since January 1940 issue. 



REFERRING YOUR PATIENTS 

FOR SPECIAL TREATMENT TO 

DURHAM — THE CITY OF MEDICINE 



Duke Medical Center 
V.A. Hospital 



lAMAD 

INN ' 



Durham County General 
McPherson's Hospital 



We are convenient to Duke Medical Center, V.A. Hospital and McPherson's Hospital. We 
offer free transportation to the hospitals every hour between the hours of 8:00 a.m. and 
6:00 p.m. Transportation after 6:00 p.m. hy special request only . Via our free van service, 
we are only 7 to 8 minutes away and your parking problems are solved. 

We offer friendly , courteous service to all our guests. So often the special needs of patients 
and their famiUes might be overlooked. We pride ourselves on our reputation for caring 
about the individuals who make the Ramada Inn Downtown their temporary home during 
their stay in Durham. 



159 tastefully decorated rooms 

Indoor heated pool 

Sauna 

Exercise room 

Whirlpool 

New Zenith Color T.V. with cablevision 

A.M.-F.M. stereo radio 

All rooms entered from inside corridor 



Lounge 

Full service restaurant 

Handicap rooms 

10% discount after 30 days 

Nightly security 

Washer and dryer 

Refrigerators available 

Efficiencies available 



We hope that when making appointments for your patients needing local accommoda- 
tions, that you will remember us at the Ramada Inn Downtown. 



For Reservations Call 
919-683-1531 

RAMADA INN DOWNTOWN 

1-40 & Duke Street 

P. O. Box 98 

Durham, N.C. 27702 



I 



Prompt, 
Economical 



Holter monitor Scanning 
i|||l^ Service and Equipment. 

Graphic Cardiology provides prompt, professional 

scanning service and the equipment for 

24-hour Holter Monitor cardiac 

K recordings. A complete report is 

••^sent to you within 24 hours. If the 
condition is serious, you will be notified 
by telephone immediately. The scan- 
ning is done by a trained Cardiovascular 
Technician with more than 7 years of 
experience in scanning and cardiology. 

For more information and a free 

detailed brochure, contact Graphic 

Cardiology, P.O. Box 713, 1239 

Pine Knolls Road, Kernersville, 

N.C. 27284. Telephone — 

919/996/5362. 




Gra phic A Cardioiog g 

n Please have a technician call for an appointment 

to discuss your Holter Monitoring Services. 
n Please send a free brochure. 



ADDRESS. 



.ZIP CODE . 



1_. 



ORGANIZATION. 



J 



Officers 
1981-1982 

NORTH CAROLINA MEDICAL 
SOCIETY 



President Josephine E. Newell, M.D. 

Raleigh Townes, Apt. 47, 525 Wade Ave., Raleigh 27605 

President-Elect Marshall S. Redding, M.D. 

1142 N. Road St., Elizabeth City 27909 

First Vice-President John W. Foust, M.D. 

3535 Randolph Rd., Charlotte 28222 

Second Vice-President Emery C. Miller, Jr., M.D. 

Bowman Gray, Winston-Salem 27103 

Secretary Jack Hughes, M.D. 

923 Broad St., Durham 27705 (1982) 

Speaker Henry J. Carr, Jr., M.D. 

603 Beaman St., Clinton 28328 

Vice-Speaker T. Reginald Harris, M.D. 

808 Schenck St., Shelby 28150 

Past-President Frank Sohmer, M.D. 

2240 Cloverdale Ave., Ste. 88, Winston-Salem 27103 

Executive Director William N. Hilliard 

222 N. Person St., Raleigh 27611 

Councilors and Vice-Councilors — 1981-1982 

First District Robert E. Lane, M.D. 

Chowan Med. Ctr., Edenton 27932 (1983) 

Vice-Councilor James M. Watson, M.D. 

1134 N. Road St., Elizabeth City 27909 (1983) 

Second District Charles P. Nicholson, Jr., M.D. 

3108 Arendell St., Morehead City 28557 (1982) 

Vice-Councilor Alfred L. Ferguson, M.D. 

6 Doctors Park, Stantonsburg Rd., Greenville 27834 (1982) 

Third District R. Bertram Williams, Jr., M.D. 

1414 Medical Center Dr., Wilmington 28401 (1982) 

Vice-Councilor Charles L. Garrett, Jr., M.D. 

P.O. Box 1358, Jacksonville 28540 (1982) 

Fourth District Robert H. Shackelford, M.D. 

238 Smith Chapel Rd., Mt. Olive 28365 (1983) 

Vice-Councilor Lawrence M. Cutchin, Jr., M.D. 

P.O. Box 40, Tarboro 27886 (1983) 

Fifth District Bruce B. Blackmon, M.D. 

P.O. Box 8, Buies Cr;ek 27506 (1984) 

Vice-Councilor Giles L. Cloninger, Jr., M.D. 

115 Main St., Hamlet 28345 (1984) 

Sixth District W. Beverly Tucker, M.D. 

Ruin Creek Rd., Henderson 27536 (1983) 

Vice-Councilor C. Glenn Pickard, Jr., M.D. 

N.C. Memorial Hospital, Chapel Hill 27514 (1983) 

Seventh District James B. Greenwood, Jr., M.D. 

4101 Central Avenue, Charlotte 28205 (1984) 

Vice-Councilor Thomas L. Dulin, M.D. 

P.O. Box 220892, Charlotte 28222 (1984) 

Eighth District Shahane R. Taylor, Jr., M.D. 

348 N. Elm St., Greensboro 27401 (1982) 

Vice-Councilor L Gordon Early, M.D. 

2240 Cloverdale Ave., Ste. 192, Winston-Salem 27103 (1982) 

Ninth District Jack C. Ev.\ns, M.D. 

244 Fairview Dr., Lexington 27292 (1982) 

Vice-Councilor Benjamin W. Goodman, M.D. 

24 Second Ave., N.E., Hickory 28601 (1982) 

Tenth District Charles T. McCullough, Jr., M.D. 

Bone & Joint Clinic, Doctors Dr., Asheville 28801 (1984) 

Vice-Councilor George W. Brown, M.D. 

102 Brown Ave., Hazelwood 28738 (1984) 

Section Chairmen — 1981-1982 

Allergy & Clinical Immunology 



Anesthesiology J. LeRoy King, M.D. 

3600 New Bern Ave., Raleigh 27610 

Dermatology Charles E. Cummings, M.D. 

281 McDowell Street, Asheville 28803 

Emergency Medicine 

Family Practice Hal M. Stuart, M.D, 

180-C Parkwood Dr., Elkin 28621 

Internal Medicine William R. Bullock, M.D. 

217 Travis Avenue, Charlotte 28204 

Neurological Surgery Robert E. Price, Jr., M.D. 

1830 Hillandale Rd., Durham 27705 

Neuroloiiv & Psychiatry Assad Meymandi, M.D. 

1212 Walter' Reed Road, Fayetteville 28304 

Nuclear Medicine William McCartney, M.D. 

N.C. Memorial Hosp., Dept. of Nuclear Medicine, 
Chapel Hill 27514 

Obstetrics & Gynecology Talbot E. Parker, Jr., M.D. 

2400 Wayne Memorial Drive, Ste. K, Goldsboro 27530 

Ophthalmology J. Lawrence Sippe, M.D. 

1350 S. Kings Drive, Charlotte 28207 

Orthopaedics Richard N. Wrenn, M.D. 

1822 Brunswick Avenue, Chariotte 28207 

Otolaryngology & Maxillofacial 

Surgei-y Walter R. Sabiston, M.D. 

400 Glenwood Ave., Kinston 28501 

Patholofiy Ron Edwards, M.D. 

3000 New Bern Ave., Raleigh 27610 

Pediatrics DavidT. Tayloe, M.D. 

608 E. 12th St., Washington 27889 

Plastic & Reconstructive 

Surgery Andrew W. Walker, M.D. 

2215 Randolph Rd., Charlotte 28207 

Public Health & Education Verna Y. Barefoot, M.D. 

2504 Old Cherry Point Rd., New Bern 28560 

Radiology Luther E. Barnhardt, Jr., M.D. 

Executive Park, Ste. 203, Asheville 28801 

Surgery Carl A. Sardi, M.D. 

Climax 27233 

Urology Donald T. Lucey, M.D. 

P.O. Box 17908, Raleigh 27619 

Delegates to the American Medical Association 

James E. Davis, M.D., 2609 N. Duke St., Ste. 402, Durham 27704 

— 2-year term (January 1, 1981-December 31 , 1982) 
John Glasson, M.D., 2609 N. Duke St., Ste. 301, Durham 27704 — 

2-year term (January I. 1981-December 31, 1982) 
David G. Welton, M.D., 3535 Randolph Rd., lOI-W, Charlotte 

2821 1 — 2-year term (January 1, 1980-December 31, 1981) 
Frank R. Reynolds. M.D., 1613 Dock St., Wilmington 28401 — 

2-year term (January I, 1981-December 31 , 1982) 
Louis deS. Shaffner, M.D., Bowman Gray, Winston-Salem 

27103 — 2-year term (January 1, 1980-December 31, 1981) 

Alternates to the American Medical Association 

E. Harvey Estes, Jr., M.D., Duke Med. Ctr., Box 2914, Durham 
27710 — 2-year term (January 1, 1981-December 31, 1982) 

Charles W. Styron, M.D.,6l5St. Mary's St., Raleigh 27605 — 
2-year term (January 1, 1980-December 31, 1981) 

D. E. Ward, Jr., M.D., 2604 N. Elm St., Lumberton 28358 — 
2-year term (January 1, 1980-December 31 , 1981) 

Jesse Caldwell, Jr., M.D., 1307 Park Lane, Gastonia 28052 — 
2-year term (January 1. 1981-December 31 , 1982) 

Frank Sohmer, M.D., 2240 Cloverdale Ave., Ste. 88, Winston- 
Salem 27103 —2-year term (January 1, 1981-December 31, 1982) 



692 



Vol. 42, No. 10 



J 



The Official 

North Carolina Medical Society 
Disability Income Program 

Since 1939 
Its Advantages Are Clear 

The only continuous Disability Plan for over 40 years — Same Carrier (Continental 
Insurance Co. of N.Y.) also underwrites over 1 00 other state professional societies. 
Same Professional Administrator (Crumpton Co. of Durham, N.C.) who also serves 
the other major professions in N.C. 

Where established Record of personal claim service to Society members is well 
known! Our best references come from our doctors, C.P.A.'s and attorneys. Over 
one million dollars paid to disabled N.C. physicians over the past several years. 

Extremely liberal contracts — Liberal Definitions as to disability — No Medical 
exams — No integration with other insurance — No income restrictions — 
Guaranteed Renewable contracts — wide range of options on Benefits — waiting 
periods — Residual — including clinic group coverage for all employees!! 

Lastly, Economy of Premium continues to be an important reason for participation 
in your Sponsored Society plan. This results from high group participation and 
Society support! 

These are just a few of the salient points why we continue to be the recognized 
source for quality Disability Income coverage by both doctors and professional 
financial advisors throughout N.C. 

For Information or Personal Assistance Please Write or Call Toll Free 




J. L. & J. Slade Crumpton, Inc. 

Professional Group Insurance Brokers 

P.O. Box 8500 — Academy Center 

Durham, N.C. 27707 

919-493-2441 — 1-800-672-1674 






N.C. Medical — N.C. Dental 



Approved Insurers to: 
N.C. Bar Groups — N.C.A.I.A.s — N.C. Engineers — N.C.C.P.A.'s 



NORTH CAROLINA MEDICAL SOCIETY 
APPROVED INSURANCE PROGRAMS 

Major Hospital and Nurse Expense Insurance 

$25,000 maximum benefit: choice of deductibles from $100 to $1 ,000: benefits 
paid regardless of other insurance 

In Hospital Indemnity Insurance 

Benefits available from $30 to $75 per day: pays regardless of other insurance 

Excess Major Medical Insurance 

$250,000 maximum: choice of $15,000 or $25,000 deductible 

Term Life Insurance 

Coverage from $10,000: dependents and employees eligible 

Business Overhead Expense Insurance 

Monthly benefits from $200 to $3,000 per month : benefits payable after 31 days 
of disability retroactive to the first day of disability: benefits payable up to 12 
consecutive months: premiums are tax deductible as a business expense 

Each of the above plans may qualify for use by professional corporations. 

We have been working with physicians in North Carolinafor more than FORTY- 
FIVE years. 



Mrs. Gladys Madden — Office Manager 
WRITE OR CALL FOR FURTHER INFORMATION 

GOLDEN-BRABHAM INSURANCE AGENCY, INC. 

108 East Northwood St., P.O. Drawer 6395 

Across Street from Cone Hospital 

Greensboro, N.C. 27405 

Tel: (919) 2753400 or 275-5035 



h vitro data show 




l>Jeolin 

E;h tablet contains 324 mg aspirin, 225 mg magnesium 
c bonate and 200 mg calcium carbonate. 

lias greater 
iicid-neutralizing 
(iffectiveness than 
/^scriptinWD 

r^OLIN contains two proven effective acid- 
rutralizers, magnesiunn carbonate and calcium 
C'bonate. 

/criptin A/D, on the other hand, is formulated 
vth magnesium hydroxide and aluminum hydroxide, 
/jminum hydroxide has been reported to be a 
porly effective acid-neutralizer.'' Additionally, 
d'ing of this particular buffer, as must be done 
fi tablet use, alters its structure, further reducing 
aiacid efficacy.^ 



It is not suprising, therefore, that NEOLIN proved superior 
to Ascriptin A/D in two separate in vitro tests* designed to 
evaluate the acid-neutralizing capacity of buffered aspirin. 
These studies showed that NEOLIN had 1 7.2% to 48.2% 
greater acid-neutralizing capacity than did Ascriptin A/D. 





rest 1 Total Acid-Neutralizing Capacity (mEq 






Neolin 16.9 














Ascriptin A/D 11.4 










1 





Test II Total Acid-Neutralizing Capacity (mEq) 






Neolin 17.0 














AscrlptinA/D 14.5 










1 



2. 



Harvey, S.C.: "Gastric antacids and digestants," in Goodman, L.S. 
and Gilman, A. (eds): Pharmaceutical Basis of Tlierapeutics, The, 
ed 6, New York: Macmillan Publishing Co., Inc., 1 980, p 991 . 
Garnett, W.R.; "Antacids," in Apple, W. (ed): Handbook of 
Nonprescription Drugs, ed 6, Washington, D.C.: American 
Pharmaceutical Association, 1979, p 6. 

* Bristol-Myers Test Method designed to evaluate the acid- 
neutralizing capacity of buffered aspirin preparations using single 
tablet samples of NEOLIN and Ascriptin A/D. Each product stirred 
for 1 5 minutes in an excess of 0. 1 N HCI at 25 °C (Test I) and 
37 °C (Test II) and back titrated with NaOH to pH 2.8. 



m 



E ISTOL-MYERS II PROFESSIONAL PRODUCTS 



In vivo data show 






'^^ 



/^^ 



^ 



^ 



^w 



^ 








^ 
^ 

^ 



^ ^1^ 

> 



With greater acid-neutralizing capacity, 



,® 



Neolin 

gets relief into 
circulation 
faster than 
Ascriptin" A/D 



When salicylate blood levels of NEOLIN and 
Ascriptin A/D were compared in three separate 
crossover studies, total amounts were found to be 
higher for NEOLIN up to one hour after ingestion. 
(Volunteers took 2 five-grain tablets of either 
medication.) More rapid absorption with NEOLIN 
means more rapid availability for pain relief, par- 
ticularly important to patients with osteoarthritis. 












Total Salicylate mcg/ml plasma 

Neolin 

Ascriptin A/D "™" 



STUDY II (40 Subjects 




Total Salicylate mcg/ml plasma 

Neolin 

Ascriptin A/D ==~~ 



STUDY III (29 Subject 





nlCOliri'the aspirin for today— and every 



Each capsule-shaped, scored tablet contains 324 mg 
aspirin, 22 5 mg magnesium carbonate and 200 mg 
calcium carbonate. 



© 1981 Bristol-Myers Company 




PRESIDENT'S NEWSLETTER 

NORTH CAROLINA MEDICAL SOCIETY 



NO. 5 

Dear Colleague: 



OCTOBER 1981 



After five solid days of meetings at the Committee Conclave, I came home weary 
and "rump-sprung" but extremely happy because of the marvelous job done by all 
of the committee members. I am told that we had the largest and best attend- 
ance ever recorded at a Committee Conclave. Every committee meeting was well 
attended by interested, willing, working physicians. The weather was perfect 
in Southern Pines and some cynics were sure that at least a few of our physi- 
cians would slip over to Pinehurst to that big golf tournament. "Oh, ye of 
little faith!" Those hardworking physicians stayed in those meetings and 
shouldered those responsibilities! I am so grateful to you all! 

The Committee Liaison to the Department of Human Resources was concerned over 
the state personnel regulations governing the qualifications for appointment 
as Local Health Directors. Recognizing that medical doctors, academically 
trained in Public Health, "can best deal with the extremely complex Public 
Health Programs," it was resolved that the Secretary of Human Resources, Sarah 
T. Morrow, M.D., be urged to seek the necessary changes in those regulations. 
The resolution states: "Acceptable candidates must have completed or be enrolled 
in a prescribed graduate education program in Public Health and must have had 
administrative experience in a health field." Is that too much to ask? After 
all, we are constantly admonished that there is a plethora (and will be more) 
of physicians who can fill these positions. Who demanded that there be more 
graduates of medical schools? The "Feds"? 

God bless Vice-President John W. Foust, who has sired our gigantic membership 
drive! Let us not forget Deanna Godwin (NCMS Administrative Assistant Member- 
ship Services). At the meeting of the Committee on Membership, it was apparent 
that the two of them have looked under every North Carolina rock for physician 
membership. Some members confessed to having received three or more letters 
from John. An excellent informational slide program was presented by Elizabeth 
Kanof, M.D. (Chairman, Committee on Communications). If you need a county 
society program, please call Liz Kanof — because — she has the answer! We 
need new members — and — they need the North Carolina Medical Society! 

Take a minute to remember our good friend and colleague, Thornton R. Cleek, M.D. 
Thornton served us all — through the North Carolina Academy of Family Practice - 
as well as serving as Councilor of the North Carolina Medical Society and as 
an elected member of the North Carolina Commission for the Division of Health 
Services. It is my sad duty to inform you of Thornton's untimely demise in 
September. Unfortunately, the Executive Council was charged with the respon- 
sibility of appointing a member to fill the unexpired term on this Commission. 
On the recommendation of the Nominating Committee, the Executive Council elected 
George W. Brown, M.D., Hazelwood, North Carolina, to fill the unexpired term, 
and we are grateful that Dr. Brown has consented to serve in this capacity. 
A memorial tribute in memory of Dr. Cleek, presented by Vice-Speaker Reginald 
Harris, was passed unanimously by the Executive Council. 

Although gravely handicapped by the failure of the Federal Government to final- 
ize budget cuts in the Medicaid Program, the Committee on Social Services 



-2- 



Programs met 3^ hours with Sarah T. Morrow, M.D., Secretary, N. C. Department 
of Human Resources, in this regard. Unfortunately, that same night. President 
Ronald Reagan, in a televised speech announced that Medicaid cuts will be more 
severe than previously stated. All was not in vain! The other committee mem- 
bers were able to discuss their ideas with Dr. Morrow (also a committee member), 
Barbara D. Matula (Director, N. C. Division of Medical Assistance), and Lillian 
J. Todd (Division of Medical Assistance Nurse Consultant). We all agreed that 
the number of Federal dollars made available will be the determining factor 
influencing impending changes in the North Carolina Medicaid Program. 

One of our hardest working and most effective committees is the Committee on 
Physicians' Health & Effectiveness, chaired by Theodore ("Ted") Clark, M.D. , 
of Pinehurst. The members of this committee contribute many hours each year 
to the work of this worthwhile effort. Their time is devoted to working, one 
on one, with our less fortunate colleagues who have fallen victim to alcohol, 
drugs or mental illness. The Committee recommended that the North Carolina 
Medical Society encourage contributions to the North Carolina Medical Society 
FOUNDATION, INC., earmarked for assistance to physicians through the Committee 
on Physicians' Health and Effectiveness. All contributions to the FOUNDATION 
are TAX-EXEMPT . The Executive Council concurred and I commend this effort to 
you when considering your charitable donations each year. 

Serious consideration is being given to the construction of an additional two 
floors to our Headquarters Office Building. Additional space has become a 
major problem for both the Medical Society and the Medical Mutual Insurance 
Company. Accordingly, the Executive Council directed the President to appoint 
an "ad hoc Committee on Feasibility Study for Additional Floors to Medical 
Society Building". Voting members of the Committee are: 

Thomas B. Dameron, Jr., M.D. (Chairman) 

A. Hewitt Rose, Jr., M.D. 

E. Thomas Marshburn, Jr., M.D. 

Robert H. Shackelford, M.D. 

Ex Officio members are: 



Ernest B. Spangler, M.D. 
Shahane R. Taylor, Jr., M.D. 
Josephine E. Newell, M.D. 
William N. Hilliard 
Garland R. Pace 



!! 



The Committee is to report to the Executive Council at its February 1982 meeting. 

Again, thank you for your fellowship and your participation in the North 
Carolina Medical Society. 



My best to you and your family! 




Joseaftine E. Newell, M.D. 
Presadent 



?AIN AND TENSIO 

Rouble fault for ■ 

[weekend warrion 



\CE THE ACHE 




tquagesic® 

meprobamate and ethoheptazine citrate with aspirin) Wyeth 

wofold analgesic action teamed with time-proven efficacy against 
oncurrent anxiety and tension in patients with musculosl<eletal disease* 



UAGESrC— Abbreviated Summary 



INDICATIONS: Based on a tevie*v o' Ihis drug Dy the 
National Academy □! Sciences— National Research 
Counai and Of other intormaliori FDA has classified 
Jie indications as follows 

"Possibly" efleclive (or ihe treatmenl o( pain accom- 
oanied by tension and or anxiety in patients wilh mus- 
luioskeielal disease or tension headache, 
-inai classification o\ the less-than-eHeciive indications 
equires further investigation 

The effectiveness of Equagesic in long-term use. i e 
■nore than (our rnonths has not been assessed by sys- 
■ematic clmical studies The physician should periodi- 
cally reassess usefulness ol the drug (or the individual 
jalient 



NTHAJNDI CATIONS: Equagesic should not be given to 
'vwjuals with a history of sensitivity or severe intolerance 
■spmn. meprobamate or ethoheptazine curate 
RNINGS: Careful supervision o' dose and amounts ore- 
bed for patients is advised, especially with those paiienis 
ii known propensfty for taking eicessrve quantities of drugs 
'^essive and prolonged use in susceptible persons e g 
|)holics. former addicts and other severe psychoneurot- 
' "las been reported to result in dependence on or habil- 
|on to the dnjg Where excessive dosage rtas continued 
^weeks or months dosage should be reduced gradually 
\-«r than abruptly stopped, since withdrawal of a "crutch' 
1/ preapitate withdrawal reaction ol greater proportions 
ji thai for which the drug was onginally pfescnbed Abrupt 
JOTTlinijance ol doses m excess ol the recommended dose 
I resulted m some cases in the occurrence ol epiteptilorm 
ures 
'■aal care should be taken to warn patients taking mepro- 
late that tolerance to alcohol may be lowered wrth result- 
slowing of reaction time and impairment o' judgment and 
, rdination 

VGE IN PREGNANCY AND LACTATION; An Jncrea&ed 
y o( congenital malformations associated with the use 



ol minor tranquilizers (meprobamate, chlordiazepoxlde, 
and diazepam) during ihe lirst [rimesler ol pregnancy 
has been suggested m several studies. Because use of 
these drugs is rarely a matter ol urgency, theic use dur- 
ing Ihis penod should atmosl always te avoided The 
possibility thai a woman ol child-bearing potential may 
be pregnant at the lime o( institution o( therapy should 
be considered Patients should be advised that il they 
become pregnant during therapy or intend to becorne 
pregnant they should communicate with their physi- 
cians about the desirability of discontinuing the drug. 
Meprobamate passes the placental bamer it is present 
both in umbilical-cord blood at or near maternal plasma 
levels and in breast milh ol lactaling mothers at concen- 
trations two lo four limes that ol maternal plasma When 
use ol meprobamate is contemplated in breast-leeding 
patients. Ihe drug's higher concentration in breast milk 
as compared to maternal plasma levels should be 
considered 

Preparations containing aspinn should be kept out ol the 
'each ol children Equagesic is not recommended lor pa- 
tients 12 years of age and under 

PRECAUTIONS; Should drowsiness, ataxia, or visual distur- 
bance occur, the dose shouU be reduced. If symptoms con- 
tinue, patients should not operate a motor vehicle or any 
dangerous machinery 

Suicdai attempts with meprobamate have resulted in coma 
shock, vasomotor and respiratory collapse, and anuria Very 
(ew suicidal attempts were fatal, although some patients in- 
gested very large amounts o( the drug (20 lo 40 gm| These 
doses are much greater than recommended The drug should 
be given cautiously and m small amounts, to patients who 
have suicidal tendencies In cases where excessive doses 
have been taken sleep ensues rapidly and blood pressure 
pulse, and respiratory rates are reduced to basal levels Hy- 
pervenMalion has beer reported occasionally Any drug re- 
maining in \he stomach should be removed and symptomatic 
treatment given Should respiration Ciecome very sfiallow ano 
slow. CNS stimulants eg catleine Metrazol or ampheta 



mine, may be cautiously administered II severe hypotension 
develoos. pressor amines should be used parenlerally to re- 
store blood pressure to norma' levels 

ADVERSE REACTIONS- A small percentage Of patients 
r^ay expenence nausea with or without vomiting and epigas- 
tric distress Dizziness occurs rarely when meprobamate and 
ethoheptazine curate with aspinn is administered in recom- 
mended dosage The meprobamate may cause drowsiness 
but as a rule this disappeais as therapy is continued Should 
drowsiness persist and be associated with ataxia this symp- 
tom can usually be controlled by decreasing the dose but 
occasionally it may be desirable to administer central stimu- 
lants such as amphetamine or mephentermme sulfate con- 
comitantly to control drowsiness 

A clearly related side eflect to the administration ol mepro- 
tjamate is the rare occurrence of allergic or idvosyncralic re- 
actions This response develops, as a njle in patients who 
have had only 1-4 doses of meprobamate and have not had 
a previous contact with the drug Previous history ol allergy 
may or may not be related to Ihe incidence of reactions 
Mild reactions are characlenzed by an itchy urticanal or ery- 
thematous, maculopapular rash which may be generalized 
or confined to the groin Acute nonthrombocytopenic purpura 
with cutaneous petechiae ecchymoses, penpherai edema, 
and lever have also been reported 

More severe cases observed only very rarely, may also have 
other allergic responses including lever, tainting spells an- 
gioneurotic edema, bronchial spasms hypotensive crises |l 
latai case), anaphylaxis stomatitis and prociitis H easel and 
hyperthermia Treatment should be symptomatic such as 
administration o! epinephrine antihistamine and possibly 
hydrocortisone Meprobamate should be stopped and rein- 
strlution ol iherapy shoukj not be attempted 
Rare cases have been reported where patients receiving me- 
probamate suffered Irom aplastic anemia |l fatal casei 
thrombocytopenic purpura. agranukJcyiosiE and hemolytic 
anemia In nearly every instance reported, other toxic agents 
Known to have caused these conditions have beer associ- 
ated with meprobamate A few cases of leukopenia dunng 



continuous adminislraiHXi Ol meprobamate are reported most 
ol these returned to normal without disconlinuation of the 
drug 

Impairment ol accommodation and visual acuity has been 
reported rarely 

OVERDOSE; Two instances ol acddenlal or intentional sig- 
nificant overdosage with ethoheptazine cinate combined with 
aspinn have been reported These were accompanied by 
symptoms ol CNS depression irKluding drowsiness and light- 
headedness, with uneventlul recovery However on the basis 
ol pharmacological data it may be anticipated that CNS stim- 
ulation cou'd occur Other antiapated symptoms would in- 
clude nausea ar>d vomiting Appropnale Iherapy of Signs and 
symptoms as they appear is the only recommendation pos- 
sible at this time (Overdosage with ethoheptazine combined 
with aspmn would probably produce the usualsymptomsand 
signs ol salicylate intoxication Observation and treatment 
should include induced vomiting or gasinc lavage speafic 
parenteral electrolyte therapy lor ketoacidosis and dehydra- 
tion watching for evidence ol hemorrhagic manifestations 
due to hypoprothrombinemia which, il it occurs, usually re- 
guires whole-blood transfusions 

DESCRIPTION: Each EquageSiC tablet contains 150 mg me- 
probamate 75 mg elhoheplazine citrate and 250 mg aspinn 

Copyright c 1981, Wyeth Laboraiones 
All rights reserved 

'This dnjg has been evaluated as possibly 
effective for this indication 

Wyeth Laboratories 

■■ ' Philadelphia. PA 19101 



idA 




/^l^ 



^■ 



.^AVi 








for mild to moderate pain 

Wygesid® 



(65 mg propoxyphene HCI and 650 mg acetaminophen) Wyeth 

More than twice as much acetaminophen as the leading combination plus a full 
therapeutic dose of propoxyphene... all in a convenient, economical single tablet. 



I 



WYGESIC— Abbreviated Summary 
INDICATION: For the relief of mild-to-moderale pain 
CONTRAINDICATION: Hypersensitivity to propox- 
vptiene or lo aceiaminophen 

WARNINGS: CNS ADDITIVE EFFECTS AND OVER- 
DOSAGE Propoxyphene in combination with alcofiol 
Iranqiiilizers, sedative-hypnotics or other CNS de- 
pressants has an additive depressant effect Pa- 
tients taking ihis drug should De advised o' ihe additive 
effect and warned not to exceed ihe dosage recom- 
mended Tome effects and lalahties have occurred 
following overdoses of propoxyphene alone or m 
comDmation with other CMS depressants Most of 
these paiienis had histories of emotional disturb- 
ances or suicidal ideation or ailempts. as well as 
misuse of tranquilizers, alcohol, or other CNS-active 
drugs Caulion should be exercised m prescribing 
large amounts of propoxyphene for such patients 
[see Management of Overdosage) 
DRUG DEPENDENCE: Propoxyphene can produce 
drug dependence characterized by psychic depend- 
ence and less frequently physical dependence and 
tolerance II will only partially suppress the with- 
drawal syndrome m individuals physically dependent 
on morphine or oiher narcotics The abuse liability of 
propoxyphene is qualitatively similar to codeine s al- 
though quanlilatively less and propoxyphene should 
be prescribed with the same degree of caution ap- 
propfiale lo the use of codeine 

USAGE IN AMBULATORY PATIENTS: Propoxy- 
phene may impair Ihe mental and/or physical abilities 
required tor potenlially hazardous tasks, e g driving 
a car or operating machinery Patients should be 
cautioned accordingly 

USAGE IN PREGNANCY; Sate use m pregnancy 
has not been established relative lo possible ad- 
verse effects on fetal development INSTANCES OF 
WITHDRAWAL SYMPTOMS IN THE NEONATE 
HAVE SEEN REPORTED FOLLOWING USAGE 
DURING PREGNANCY Therefore propoxyphene 
should not be used m pregnant women unless, in the 



judgement of the physician the polentiai benefits 
outweigh the possible hazards 
USAGE IN CHILDREN: Propoxyphene is not rec- 
ommended for children because documented clinical 
experience has been msuificieni lo establish safety 
and a suitable dosage regimen m the pediatric group 
PRECAUTIONS: Contusion anxiety, and tremors 
have beeri reported m a few patienls receiving pro- 
poxyphene concomitantly with orphenadnne The CNS 
depressant effect of propoxyphene may be additive 
with olher CNS depressants, including alcohol 
ADVERSE REACTIONS- The most frequent ad- 
verse reactions are dizjmess sedation nausea, and 
vomiting These seem more prommeni m ambulatory 
than m nonambulatory patients some of these re- 
actions may be alleviated il the patient lies down 
Other adverse reactions include constipation, ab- 
dominal pain, skin rashes, iighi-headedness head- 
ache weakness, euphoria, dysphoria, and minor 
visual disturbances The chronic ingestion of propox- 
yphene in doses over 800 mg per day has caused 
loxic psychoses and convulsions Cases ol liver dys- 
function have been reported 

DRUG INTERACTIONS: Propoxyphene in combi- 
nation with alcohol tranquilizers, sedative-hypnot- 
ics and other CNS depressants has an additive 
depressant effect Patients taking Ihis drug should 
be advised of the additive effect and warned not lo 
exceed ihe dosage recommended (see Warnings) 
Confusion anxiety and tremors have been reported 
in a lew patients receiving propoxyphene concomi- 
tantly with orphenadnne 

MANAGEMENT OF OVERDOSAGE: SYMPTOl^S 
The manifestations ol senous overdosage with pro- 
poxyphene are Similar to those of narcotic overdos- 
age and include respiratory depression (a decrease 
in resptralory rate and or tidal volume. Cheyne- 
Stokes respiration, cyanosis), extreme somnolence 
progressing lo stupor or coma, pupillary constnciion, 
and circulatory collapse in addition to these char- 
aclerislics which are reversed by narcotic antago- 



nists Such as naloxone there may be other effects 
Overdoses of propoxyphene can cause delay of car- 
diac conduction as well as focal or generalized con- 
vulsions, a prominent feature m most cases ol severe 
poisoning Cardiac arrhythmias and pulmonary edema 
have occasionally been reported, and apnea, car- 
diac arrest, and death have occurred 
Symploms ol massive overdosage with acetamino- 
phen may include nausea, vomitmg anorexia, and 
abdominal pain beginning shortly after ingestion and 
lasting for 12 lo 24 hours However early recognition 
may be difficult smce eany symptoms may De mild 
and nonspecific Evidence of liver damage is usually 
delayed. After the mitial symptoms, the'patienl may 
leel less ill. however laboratory determinations are 
likely lo show a rapid rise m hver enzymes and bili- 
rubin In case ol serious hepatotoxiciiy. .aundice co- 
agulation defects, hypoglycemia, encephalopathy, 
coma and deaih may follow Renat failure due to 
tubular necrosis, and myocardiopathy, have also been 
reported. 

Ingestion of 10 grams or more ol acetammoohen 
may produce hepaloloxiciiy A l3-gram dose has re- 
portedly been lalai 

TREATMENT: Primary attention should be given to 
the reeslablishmeni of adequate respiratory ex- 
change through provision of a patent airway and in- 
stitution of assisted or controlled venlilation The 
narcotic antagonists, naloxone, nalorphine and lev- 
aiiorphan. are specific antidotes against the respira- 
tory depression produced by propoxyphene An 
appropriate dose of one of these antagonists should 
be administered preferably 1 v .simultaneously withef- 
torts at respiratory resuscitation and the aniagonist 
should be repeated as necessary uniii the patients 
condition remains satisfactory In addition lo a nar- 
colic anlagomsl Ihe patient may require careful titra- 
tion with an anticonvulsant to control seizures 
Analeptic drugs (e g caffeine or amphetamine) should 
not be used because of their tendency to precipitate 
convulsions 



Oxygen IV fluids vasopressors and other supporj^. 
tive measures should be used as indicated Gaslr«f 
lavage may be helplui Aclivaled charcoal can al 
sorb a significant amount ol ingested propoxyphene' 
Dialysis IS ol little value m poisonmg by propoxy- 
phene alone Acetaminophen is rapidly absorbed j 
and etfoas to remove the drug Irom Ihe body shoum 
not be delayed Copious gaslnc lavage and or mduc-; 
tion of emesis may be indicated Activated charcoa, 
IS probably ineffective unless administered almos'; 
immediately after acetaminophen ingestion Neither! 
lorced diuresis nor hemodialysis appears lo be e'--' 
fective in removing acetaminophen Smce acel3mi-| 
nophen in overdose may have an antidiuretic elfec» 
and may produce renal damage, administration ol 
fluids should be carefully monitored to avoid over^ 
load II has been reported that mercaplamme icysj 
leamme) or other thiol compounds may prolecl agaiisj 
liver damage if given soon after overdosage (8-U 
hours) N-acetylcySieine is under investigation as i 
less loxic allernative to mercaplamme, which may 
cause anorexia, nausea, vomiting, and drowsiness 
Appropriate literature should be cbnsulled for lurthe' 
information (JAMA 237 2406-2407, 1977) 
Clinical ana laboratory evidence ol hepaioloxicity ma) 
be delayed up to one week Acetaminophen plasfn; 
levels and hait-hle may be useful m assessing lh( 
likelihood of hepatoloxicily Serial hepalic enzymf 
determinations are also recommended 

Copyright !■ 1981, Wyeth Laboratories- , 

All rights reserved, 

i 

Wyeth Laboratories ■ 

■' ' Philadelphia, PA 19101 i 



Lii 



H 



An added complication... 
n tlie treatment of bacterial bronchitis 




;l Summary. 

suit the package literature lor prescribing 
llrmalion. 

llcalionsand Usage: Ceclor' (cefaclor. Liliy) is 
! caled in ihe treatmeni of ihe following infections 
■ n caused t}y susceptible strains of the designated 

roorganisms 

ower respirator y infections , including pneumonia 
t'ied by Streptococcus pneumoniae (Diplococcus 
I'jmoniae), Haemophilus mlluenzae. andS 
( genes (group A beta-hemolytic streptococci) 

ppropriate culture and susceptibility studies 

uld be periormed to determine susceptibility of 
licausative organism to Ceclor. 

;lralndicalJon: Ceclor is contratndicaled in patients 

.1 known allergy to the cephalosporin group of 
I'biotics 

'flings; in penicillin-sensitive patients. 

' HALOSPORIN ANTIBIOTICS SHOULD BE ADMINISTERED 
TIOUSLY THERE IS CLINICAL AND LABORATORY 
)£NCE OF PARTIAL CROSS-ALLERGEMCiTV OF THE 
ICILLINS AND THE CEPHALOSPORINS, AND THERE ARE 
I 'ANCES IN WHICH PATIENTS HAVE HAD REACTIONS TO 
IH DRUG CLASSES (including ANAPHYLAXIS AFTER 
ENTERALUSE) 

ntibiotics, including Ceclor. should be administered 
i.'iously to any patient who has demonstrated some 
tn of allergy, particularly lo drugs 
cautions: If an allergic reaction to cefaclor occurs, 
'drug should be discontinued, and, if necessary, the 
ent should be treated with appropriate agents, e g , 
isor amines, antihistamines, or corticosteroids 
■rolonged use of cefaclor may result m the 
rgrowth of nonsusceptiOle organisms Careful 
ervalion of the patient ts essential If superinfection 
jfs during therapy, appropriate measures should 
aken 

lOSitive direct Coombs tests have been reported 
rog treatment with the cephalosporin antibiotics In 
siatologic studi